Provider Demographics
NPI:1790201523
Name:ADVANCE HEALTH IPA, LLC
Entity Type:Organization
Organization Name:ADVANCE HEALTH IPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-449-8962
Mailing Address - Street 1:14121 PARKE LONG CT STE 201
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1647
Mailing Address - Country:US
Mailing Address - Phone:571-449-8962
Mailing Address - Fax:
Practice Address - Street 1:14121 PARKE LONG CT STE 201
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1647
Practice Address - Country:US
Practice Address - Phone:571-449-8962
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization