Healthcare Provider Details

I. General information

NPI: 1720020852
Provider Name (Legal Business Name): ELEONORA HACKMAN-KERBYSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELEONORA HACKMAN MD

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 TAMIAMI TRL STE A
PORT CHARLOTTE FL
33952-3922
US

IV. Provider business mailing address

3434 HANCOCK BRIDGE PKWY STE 301
N FORT MYERS FL
33903-7094
US

V. Phone/Fax

Practice location:
  • Phone: 941-624-2704
  • Fax: 941-627-6066
Mailing address:
  • Phone: 877-856-3774
  • Fax: 239-599-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2003014738
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036-110911
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME104987
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: