Provider Demographics
NPI:1033977665
Name:DIVERGE HEALTH IPA OF NY LLC
Entity Type:Organization
Organization Name:DIVERGE HEALTH IPA OF NY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:PANTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-917-9000
Mailing Address - Street 1:500 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-1865
Mailing Address - Country:US
Mailing Address - Phone:941-718-9000
Mailing Address - Fax:
Practice Address - Street 1:500 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:IL
Practice Address - Zip Code:60022-1865
Practice Address - Country:US
Practice Address - Phone:941-718-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty