Provider Demographics
NPI:1134314602
Name:PROVENA SERVICE CORPORATION
Entity Type:Organization
Organization Name:PROVENA SERVICE CORPORATION
Other - Org Name:PROVENA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL REPORTING SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-806-3111
Mailing Address - Street 1:9223 W SAINT FRANCIS RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-8330
Mailing Address - Country:US
Mailing Address - Phone:815-806-3111
Mailing Address - Fax:
Practice Address - Street 1:405 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-4451
Practice Address - Country:US
Practice Address - Phone:217-431-6330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVENA SERVICE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid
IL=========004Medicaid