1063719318 NPI number — PUNTA GORDA HMA PHYSICIAN MANAGEMENT LLC

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 1063719318 NPI number — PUNTA GORDA HMA PHYSICIAN MANAGEMENT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUNTA GORDA HMA PHYSICIAN MANAGEMENT LLC
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:
6
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:
1063719318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5811 PELICAN BAY BLVD
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34108-2733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-598-3131
Provider Business Mailing Address Fax Number:
239-592-0438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
713 E MARION AVE
Provider Second Line Business Practice Location Address:
SUITE 133
Provider Business Practice Location Address City Name:
PUNTA GORDA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33950-3872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-639-6616
Provider Business Practice Location Address Fax Number:
941-639-1716
Provider Enumeration Date:
02/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SENIOR DIRECTOR PROVIDER ENROLLMENT
Authorized Official Telephone Number:
615-465-3334

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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