Basic Information
| Provider Information | |||||||||
| NPI: | 1255526687 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVENA SERVICE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVENA MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9223 W SAINT FRANCIS RD | ||||||||
| Address2: | |||||||||
| City: | FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604238330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158063111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 102 N LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618328513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174425863 | ||||||||
| FaxNumber: | 2174425040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOLAND | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCIAL REPORTING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8158063111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROVENA SERVICE CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.