Healthcare Provider Details

I. General information

NPI: 1407428238
Provider Name (Legal Business Name): COLLIER BOULEVARD HMA PHYSICIAN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8340 COLLIER BLVD STE 309
NAPLES FL
34114-3626
US

IV. Provider business mailing address

PO BOX 689022
FRANKLIN TN
37068-9022
US

V. Phone/Fax

Practice location:
  • Phone: 239-354-6380
  • Fax: 239-354-6398
Mailing address:
  • Phone: 239-354-6380
  • Fax: 239-354-6398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily 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