=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548452378
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRUECK, GOLOSOW, KIM & ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2007
-----------------------------------------------------
Last Update Date | 05/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3700 CENTRAL AVE STE 1
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33901-7649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-939-5233
-----------------------------------------------------
Fax | 239-939-9225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6842 INTERNATIONAL CENTER BLVD
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912-7129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-939-5233
-----------------------------------------------------
Fax | 239-938-2933
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. SUSAN M. HANZEVACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-939-5233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0122X
-----------------------------------------------------
Taxonomy Name | Plastic and Reconstructive Surgery Physician
-----------------------------------------------------
License Number | ME33768
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------