MEDICARE: PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053983338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	PO BOX 689022
Second Line	:
City	:	FRANKLIN
State	:	TN
Zip	:	37068-9022
Country	:	US
Telephone Number	:	615-465-7211
Fax Number	:	615-628-6877

Provider Business Practice Location Address
First Line	:	3067 TAMIAMI TRL STE 2
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-6619
Country	:	US
Telephone Number	:	941-225-8351
Fax Number	:	941-258-3519

Authorized Official
Title or Position	:	SR DIR PROV ENROLLMENT & ONBOARDING
Name	:	JENNIFER L JACKSON
Credential	:
Telephone Number	:	615-465-3334

Provider Enumeration Date	:	07/15/2021
Last Update Date	:	03/16/2022

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