Healthcare Provider Details

I. General information

NPI: 1871218966
Provider Name (Legal Business Name): PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 E MARION AVE STE 123
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: 941-766-5099
  • Fax: 961-764-0194
Mailing address:
  • Phone: 615-465-7211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L JACKSON
Title or Position: SR DIR ENROLLMENT & ONBOARDING
Credential:
Phone: 615-465-3334