Provider Demographics
NPI:1770911208
Name:PROVIDEA HEALTH PARTNERS, LLC
Entity type:Organization
Organization Name:PROVIDEA HEALTH PARTNERS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-945-6470
Mailing Address - Street 1:10260 191ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8801
Mailing Address - Country:US
Mailing Address - Phone:708-572-7606
Mailing Address - Fax:708-469-4358
Practice Address - Street 1:10260 191ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8801
Practice Address - Country:US
Practice Address - Phone:708-572-7606
Practice Address - Fax:708-469-4358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-18
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F100118986Medicare PIN