MEDICARE: EVERNORTH CARE PROVIDERS - DELAWARE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1417782244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERNORTH CARE PROVIDERS - DELAWARE PA

Provider Business Mailing Address
First Line	:	730 COOL SPRINGS BLVD STE 500
Second Line	:
City	:	FRANKLIN
State	:	TN
Zip	:	37067-7331
Country	:	US
Telephone Number	:	773-292-4800
Fax Number	:	312-564-4059

Provider Business Practice Location Address
First Line	:	232 CAPITOL ST STE 2A
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-2234
Country	:	US
Telephone Number	:	773-292-4800
Fax Number	:	312-564-4059

Authorized Official
Title or Position	:	CREDENTIALING SR. MANAGER
Name	:	GRACE BLUE
Credential	:
Telephone Number	:	773-292-4800

Provider Enumeration Date	:	09/03/2024
Last Update Date	:	09/03/2024

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