Provider Demographics
NPI:1629326269
Name:PROMED ALLIANCE ACO1 INC
Entity Type:Organization
Organization Name:PROMED ALLIANCE ACO1 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-570-7023
Mailing Address - Street 1:778 S MILITARY TRL
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-3025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:778 S MILITARY TRL
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-3025
Practice Address - Country:US
Practice Address - Phone:954-570-7023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty