=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518126192
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES S EBY MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2008
-----------------------------------------------------
Last Update Date | 06/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2666 SWAMP CABBAGE CT
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-9332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-936-1145
-----------------------------------------------------
Fax | 239-275-5074
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2666 SWAMP CABBAGE CT
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-9332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-936-1145
-----------------------------------------------------
Fax | 239-275-5074
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | CHARLES SIDNEY EBY JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 239-936-1145
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | ME15824
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------