Healthcare Provider Details

I. General information

NPI: 1750040598
Provider Name (Legal Business Name): PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 09/02/2025
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 E MARION AVE STE 121
PUNTA GORDA FL
33950-3862
US

IV. Provider business mailing address

PO BOX 689022
FRANKLIN TN
37068-9022
US

V. Phone/Fax

Practice location:
  • Phone: 941-833-1760
  • Fax: 941-205-3374
Mailing address:
  • Phone: 615-465-7211
  • Fax: 877-892-9815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA MUSIC
Title or Position: DIRECTOR PROVIDER ENROLLMENT
Credential:
Phone: 877-892-9815