=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588749618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST FLORIDA FERTILITY CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 01/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15730 NEW HAMPSHIRE CT SUITE 101
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-561-3430
-----------------------------------------------------
Fax | 239-561-6980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15730 NEW HAMPSHIRE CT SUITE 101
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-561-3430
-----------------------------------------------------
Fax | 239-561-6980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JACOB LEON GLOCK
-----------------------------------------------------
Credential | MEDICAL DOCTOR MD
-----------------------------------------------------
Telephone | 239-561-3430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VE0102X
-----------------------------------------------------
Taxonomy Name | Reproductive Endocrinology Physician
-----------------------------------------------------
License Number | ME0057264
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------