MEDICARE: PHYSICIANS MEDICAL GROUP OF SOUTHWEST FLORIDA,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	207Q00000X	Family Medicine Physician	OS002373	FL

General Provider Information

NPI Number	:	1104259035
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS MEDICAL GROUP OF SOUTHWEST FLORIDA,LLC

Provider Business Mailing Address
First Line	:	3800 COLONIAL BLVD STE 200
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33966-1075
Country	:	US
Telephone Number	:	239-936-1233
Fax Number	:	239-936-8576

Provider Business Practice Location Address
First Line	:	3800 COLONIAL BLVD STE 200
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33966-1075
Country	:	US
Telephone Number	:	239-936-1233
Fax Number	:	239-936-8576

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	BARRY K BUTLER
Credential	:	MD
Telephone Number	:	239-936-1233

Provider Enumeration Date	:	08/14/2013
Last Update Date	:	06/19/2023

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