=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902173529
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROXANN SANGIACOMO, M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2011
-----------------------------------------------------
Last Update Date | 04/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14150 METROPOLIS AVE # 4
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912-4345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-768-6060
-----------------------------------------------------
Fax | 239-768-6242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14150 METROPOLIS AVE # 4
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912-4345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-768-6060
-----------------------------------------------------
Fax | 239-768-6242
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. DONNA FERRES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-768-6060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME0056944
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------