1720020852 NPI number — ELEONORA HACKMAN-KERBYSON MD

Table of content: ELEONORA HACKMAN-KERBYSON MD (NPI 1720020852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720020852 NPI number — ELEONORA HACKMAN-KERBYSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HACKMAN-KERBYSON
Provider First Name:
ELEONORA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HACKMAN
Provider Other First Name:
ELEONORA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1720020852
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3434 HANCOCK BRIDGE PKWY
Provider Second Line Business Mailing Address:
STE 301
Provider Business Mailing Address City Name:
N FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33903-7094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-856-3774
Provider Business Mailing Address Fax Number:
239-599-2625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2450 TAMIAMI TRL
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33952-3922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-624-2704
Provider Business Practice Location Address Fax Number:
941-627-6066
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  2003014738 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: 036-110911 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ME104987 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 426403 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 124884 . This is a "BLUE CROSS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 208440818 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 947071631 . This is a "MERCY HEALTH" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00145175 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 036110911 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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