Healthcare Provider Details

I. General information

NPI: 1619064813
Provider Name (Legal Business Name): COLLIER HMA PHYSICIAN MANANGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2006
Last Update Date: 03/09/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9240 BONITA BEACH RD SE SUITE 2206
BONITA SPRINGS FL
34135-4249
US

IV. Provider business mailing address

9240 BONITA BEACH RD SE SUITE 2206
BONITA SPRINGS FL
34135-4249
US

V. Phone/Fax

Practice location:
  • Phone: 239-948-5505
  • Fax: 239-948-5583
Mailing address:
  • Phone: 239-948-5505
  • Fax: 239-948-5583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L JACKSON
Title or Position: SR DIR PROV ENROLLMENT & ONBOARDING
Credential:
Phone: 615-465-3334