Healthcare Provider Details

I. General information

NPI: 1538024989
Provider Name (Legal Business Name): PHYSICIANS REGENERATIVE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 DIAMOND CENTRE CT BLDG 100
FORT MYERS FL
33912-4367
US

IV. Provider business mailing address

6150 DIAMOND CENTRE CT BLDG 100
FORT MYERS FL
33912-4367
US

V. Phone/Fax

Practice location:
  • Phone: 239-768-6896
  • Fax: 239-204-3000
Mailing address:
  • Phone: 239-768-6896
  • Fax: 239-204-3000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS GHANEM
Title or Position: PRESIDENT
Credential:
Phone: 239-768-6396