Healthcare Provider Details

I. General information

NPI: 1033586060
Provider Name (Legal Business Name): MARY SAMOGE-WISMER OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18480 COCHRAN BLVD
PORT CHARLOTTE FL
33948-3379
US

IV. Provider business mailing address

3054 MANCINI TER
PUNTA GORDA FL
33983-3311
US

V. Phone/Fax

Practice location:
  • Phone: 941-743-4700
  • Fax:
Mailing address:
  • Phone: 941-916-0340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOT9256
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: