Healthcare Provider Details

I. General information

NPI: 1265714141
Provider Name (Legal Business Name): HAMLET HMA PPM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 ENDO LN SUITE 1
HAMLET NC
28345-4566
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 910-205-8909
  • Fax: 910-205-8952
Mailing address:
  • Phone: 239-598-3131
  • Fax: 239-592-0438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. MICHAEL L GINGRAS
Title or Position: VICE PRESIDENT
Credential:
Phone: 239-598-3131