Basic Information
| Provider Information | |||||||||
| NPI: | 1568132488 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOVIVE HEALTH - ILLINOIS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 E ROOSEVELT RD | ||||||||
| Address2: | |||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601484740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3128585112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2021 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | KOURY | ||||||||
| AuthorizedOfficialFirstName: | THEOPHILE | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMIN VICE PRESIDENT OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5103502600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.