1790898666 NPI number — ACCESS MEDICAL SOUTH, LC

Table of content: (NPI 1790898666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790898666 NPI number — ACCESS MEDICAL SOUTH, LC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACCESS MEDICAL SOUTH, LC
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:
1790898666
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12681 CREEKSIDE LN STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33919-3359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-343-8290
Provider Business Mailing Address Fax Number:
239-343-8291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9369 LAREDO AVE STE 170
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33905-4632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-343-8290
Provider Business Practice Location Address Fax Number:
239-343-8291
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SPENCE
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
239-343-6014

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ATN675402 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 021547300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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