Healthcare Provider Details

I. General information

NPI: 1386700375
Provider Name (Legal Business Name): COLLIER HMA PHYSICIAN MANAGMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 03/09/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 SAN MARCO RD UNIT 203
MARCO ISLAND FL
34145-6722
US

IV. Provider business mailing address

PO BOX 277575
ATLANTA GA
30384-7575
US

V. Phone/Fax

Practice location:
  • Phone: 239-348-4400
  • Fax:
Mailing address:
  • Phone: 866-391-6826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine 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