Healthcare Provider Details

I. General information

NPI: 1669283495
Provider Name (Legal Business Name): STAR ORTHOPEDICS AND SPINE OF FORT MYERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12610 WORLD PLAZA LN UNIT 61-2
FORT MYERS FL
33907-4076
US

IV. Provider business mailing address

1020 W OAK ST
KISSIMMEE FL
34741-4113
US

V. Phone/Fax

Practice location:
  • Phone: 561-699-6373
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HILLARY KOERNER
Title or Position: COO
Credential:
Phone: 561-699-6373