Healthcare Provider Details

I. General information

NPI: 1811288525
Provider Name (Legal Business Name): FT SMITH HMA PBC MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W BROADWAY ST
SPIRO OK
74959-2430
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 918-962-2442
  • Fax: 918-962-3895
Mailing address:
  • Phone: 239-598-3131
  • Fax: 239-592-0438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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