=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790015717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASSOCIATES IN GERIATRIC MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2010
-----------------------------------------------------
Last Update Date | 07/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6503 PLANTATION PRESERVE CIR N
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33966-8366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-798-0482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6503 PLANTATION PRESERVE CIR N
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33966-8366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-798-0482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICEMANAGER
-----------------------------------------------------
Name | PRASAD KASIREDDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-490-4362
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------