Organization
PROVENA SERVICE CORPORATION
Active
Parent organization
PROVENA SERVICE CORPORATION
Other names
Provena Medical Group
Organization subpart
Yes
Provider details
NPI number
Legal business name
PROVENA SERVICE CORPORATION
Authorized official
DANIEL BOLAND (FINANCIAL REPORTING MANAGER)
(815) 806-3111
Entity
Organization
Contact information
Practice address
102 N LOGAN AVE, DANVILLE, IL 61832-8513
(217) 442-5863
(217) 442-5040
Mailing address
9223 W SAINT FRANCIS RD, FRANKFORT, IL 60423-8330
(815) 806-3111
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
IL
Other
Enumeration date
09/10/2007
Last updated
04/20/2008
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