Basic Information
| Provider Information | |||||||||
| NPI: | 1225081888 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTUM PALLIATIVE AND HOSPICE CARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EVERCARE HOSPICE, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159028241 | ||||||||
| FaxNumber: | 2159028809 | ||||||||
| Practice Location | |||||||||
| Address1: | 6095 MARSHALEE DR | ||||||||
| Address2: | |||||||||
| City: | ELKRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210756053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103793599 | ||||||||
| FaxNumber: | 8669506039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 11/04/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ENDERLE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | O. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8602210793 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLLABORATIVE CARE HOLDINGS, LLC | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | H1538 | MD | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 347001600 | 05 | MD | MEDICAID | 411947901 | 05 | MD | MEDICAID | 411947907 | 05 | MD | MEDICAID | 411947902 | 05 | MD | MEDICAID |