| NPI | 1134314602 |
|---|---|
| Doing Business As | PROVENA MEDICAL GROUP |
| Entity Type | Organization |
| Authorized Contact | DANIEL BOLAND Financial Reporting Specialist 815-806-3111 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IL 036107495) |
| Enumeration Date | 2007-09-07 |
| Last Update Date | 2008-04-20 |