MEDICARE: FORT SMITH HMA PBC MANAGEMENT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician

General Provider Information

NPI Number	:	1023398641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT SMITH HMA PBC MANAGEMENT, LLC

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

Provider Business Practice Location Address
First Line	:	9207 HIGHWAY 71 S
Second Line	:	CISTERNA MARKET SUITE 9
City	:	FORT SMITH
State	:	AR
Zip	:	72916-9117
Country	:	US
Telephone Number	:	479-709-7275
Fax Number	:	479-709-7276

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. MICHAEL L GINGRAS
Credential	:
Telephone Number	:	239-598-3131

Provider Enumeration Date	:	08/26/2011
Last Update Date	:	11/27/2012

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