MEDICARE: HOUSECALLS MD SWFL, 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	207R00000X	Internal Medicine Physician		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417346388
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSECALLS MD SWFL, LLC

Provider Business Mailing Address
First Line	:	2656 BLUE CYPRESS LAKE CT
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-2912
Country	:	US
Telephone Number	:	239-410-3894
Fax Number	:	239-772-0267

Provider Business Practice Location Address
First Line	:	2656 BLUE CYPRESS LAKE CT
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-2912
Country	:	US
Telephone Number	:	239-410-3894
Fax Number	:	239-772-0267

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	STACY ANN HERMINA
Credential	:
Telephone Number	:	239-410-3894

Provider Enumeration Date	:	01/15/2015
Last Update Date	:	02/23/2015

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