MEDICARE: ROYAL PALM PHYSICIAN GROUP, PA

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	208D00000X	General Practice Physician	ME98117	FL

General Provider Information

NPI Number	:	1912368556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROYAL PALM PHYSICIAN GROUP, PA

Provider Business Mailing Address
First Line	:	1585 PINE RIDGE RD STE 2
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34109-2105
Country	:	US
Telephone Number	:	239-451-3143
Fax Number	:	239-451-3145

Provider Business Practice Location Address
First Line	:	1585 PINE RIDGE RD STE 2
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34109-2105
Country	:	US
Telephone Number	:	239-451-3143
Fax Number	:	239-451-3145

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KELLY A FONTANA
Credential	:	MD
Telephone Number	:	239-451-3143

Provider Enumeration Date	:	03/10/2016
Last Update Date	:	03/10/2016

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