| Evernorth Care Providers - Tennessee Pc | |
|
11350 Random Hills Rd Ste 800 Fairfax VA 22030-6044 | |
| (773) 292-4800 | |
| (312) 564-4059 |
| Full Name | Evernorth Care Providers - Tennessee Pc |
|---|---|
| Speciality | General Practice |
| Location | 11350 Random Hills Rd Ste 800, Fairfax, Virginia |
| Authorized Official Name and Position | Grace V Blue (CREDENTIALING SR. MANAGER) |
| Authorized Official Contact | 7732924800 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Evernorth Care Providers - Tennessee Pc 730 Cool Springs Blvd Ste 500 Franklin TN 37067-7331 Ph: (773) 292-4800 | Evernorth Care Providers - Tennessee Pc 11350 Random Hills Rd Ste 800 Fairfax VA 22030-6044 Ph: (773) 292-4800 |
| NPI Number | 1174304976 |
|---|---|
| Provider Enumeration Date | 10/09/2023 |
| Last Update Date | 02/14/2024 |
| Medicare PECOS PAC ID | 7911355532 |
|---|---|
| Medicare Enrollment ID | O20240205003588 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1174304976 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 208D00000X | General Practice | (* (Not Available)) | Primary |
| Provider Name | Adetutu Aina |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1710317680 PECOS PAC ID: 8820317829 Enrollment ID: I20180220001243 |
| Provider Name | Jacky Mukuna |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1538884820 PECOS PAC ID: 1153777503 Enrollment ID: I20240404002305 |
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