Provider Demographics
NPI:1598126682
Name:PROVISO PARTNERS FOR HEALTH
Entity Type:Organization
Organization Name:PROVISO PARTNERS FOR HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MPS
Authorized Official - Phone:773-655-5661
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:OFFICE OF COMMUNITY BENEFIT AND ANALYTICS
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-536-5042
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:OFFICE OF COMMUNITY BENEFIT AND ANALYTICS
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-536-5042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty