MEDICARE: MEDICAL CENTRE OF FORT MYERS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103T00000X	Psychologist
2	2084P0802X	Addiction Psychiatry Physician
3	261Q00000X	Clinic/Center
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
5	261QM0850X	Adult Mental Health Clinic/Center
6	261QM2800X	Methadone Clinic
7	261QP2300X	Primary Care Clinic/Center
8	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1356003081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL CENTRE OF FORT MYERS

Provider Business Mailing Address
First Line	:	4901 PALM BEACH BLVD STE 101
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-3252
Country	:	US
Telephone Number	:	813-252-6114
Fax Number	:

Provider Business Practice Location Address
First Line	:	4901 PALM BEACH BLVD STE 101
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-3252
Country	:	US
Telephone Number	:	813-252-6114
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEMETRIS WEAVER
Credential	:	PRESIDENT
Telephone Number	:	813-252-6114

Provider Enumeration Date	:	10/11/2021
Last Update Date	:	10/20/2021

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