=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801780069
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONNECT RPM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2025
-----------------------------------------------------
Last Update Date | 06/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 FORT WADE RD STE 100
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32081-5114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-567-6449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 FORT WADE RD STE 100
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32081-5114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-567-6449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | LISA MESEROLL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-567-6449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------