Healthcare Provider Details

I. General information

NPI: 1063719318
Provider Name (Legal Business Name): PUNTA GORDA HMA PHYSICIAN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2011
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 E MARION AVE SUITE 133
PUNTA GORDA FL
33950-3872
US

IV. Provider business mailing address

5811 PELICAN BAY BLVD SUITE 500
NAPLES FL
34108-2733
US

V. Phone/Fax

Practice location:
  • Phone: 941-639-6616
  • Fax: 941-639-1716
Mailing address:
  • Phone: 239-598-3131
  • Fax: 239-592-0438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MS. JENNIFER L JACKSON
Title or Position: SENIOR DIRECTOR PROVIDER ENROLLMENT
Credential:
Phone: 615-465-3334