Healthcare Provider Details

I. General information

NPI: 1013782861
Provider Name (Legal Business Name): PUNTA GORDA HB MEDICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 HARBOR BLVD
PORT CHARLOTTE FL
33952-5000
US

IV. Provider business mailing address

2500 HARBOR BLVD
PORT CHARLOTTE FL
33952-5000
US

V. Phone/Fax

Practice location:
  • Phone: 855-472-9219
  • Fax:
Mailing address:
  • Phone: 877-892-9815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA MUSIC
Title or Position: OA
Credential:
Phone: 877-892-9815