=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861687618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PILOT HEALTHCARE P.L.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2007
-----------------------------------------------------
Last Update Date | 03/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3501 HEALTH CENTER BLVD #2230
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34135-8127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-992-7822
-----------------------------------------------------
Fax | 239-947-5687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20791 THREE OAKS PKWY #1209
-----------------------------------------------------
City | ESTERO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33929-3670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-992-7822
-----------------------------------------------------
Fax | 239-947-5687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BRUCE MICHAEL BRIDEWELL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 239-992-7822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | ME51156
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------