1962701672 NPI number — MATERNAL FETAL MEDICINE OF S.W. FL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962701672 NPI number — MATERNAL FETAL MEDICINE OF S.W. FL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATERNAL FETAL MEDICINE OF S.W. FL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962701672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8270 COLLEGE PKWY
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-333-3826
Provider Business Mailing Address Fax Number:
239-333-0592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 HARBOR BLVD
Provider Second Line Business Practice Location Address:
UNIT 7
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33952-5038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-391-8010
Provider Business Practice Location Address Fax Number:
941-391-8013
Provider Enumeration Date:
03/21/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MENNA
Authorized Official First Name:
MARTY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE ASSISTANT
Authorized Official Telephone Number:
239-333-3826

Provider Taxonomy Codes

  • Taxonomy code: 207VM0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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