Provider Demographics
NPI:1700815099
Name:OPTUM PALLIATIVE AND HOSPICE CARE, INC.
Entity Type:Organization
Organization Name:OPTUM PALLIATIVE AND HOSPICE CARE, INC.
Other - Org Name:EVERCARE HOSPICE, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ENDERLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-221-0793
Mailing Address - Street 1:1009 WINDCROSS CT
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-2678
Mailing Address - Country:US
Mailing Address - Phone:615-224-5443
Mailing Address - Fax:844-727-9218
Practice Address - Street 1:3003 N. CENTRAL AVE.
Practice Address - Street 2:SUITE 800
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012
Practice Address - Country:US
Practice Address - Phone:866-658-4658
Practice Address - Fax:602-749-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3566251G00000X
AZHSPC3566251G00000X
251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ905747Medicaid
AZ905747OtherEVERCARE SELECT
AZ905747OtherAZ PHYSICIAN IPA
CACB202675Medicare PIN
MD553PMedicare PIN
COCOA102843Medicare PIN
AZ905747OtherEVERCARE SELECT
VAC10791Medicare PIN
PA364285Medicare PIN
AZ905747OtherAZ PHYSICIAN IPA
MOMA5124Medicare PIN
AZ905747Medicaid