MEDICARE: TRITEL CONCIERGE MEDICINE 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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1396366985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRITEL CONCIERGE MEDICINE LLC

Provider Business Mailing Address
First Line	:	6846 INTERNATIONAL CENTER BLVD STE A
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-7155
Country	:	US
Telephone Number	:	239-244-9670
Fax Number	:	239-244-9670

Provider Business Practice Location Address
First Line	:	6846 INTERNATIONAL CENTER BLVD STE A
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-7155
Country	:	US
Telephone Number	:	239-244-9670
Fax Number	:	239-244-9670

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. PAUL TRITEL
Credential	:	MD
Telephone Number	:	239-244-9670

Provider Enumeration Date	:	05/05/2020
Last Update Date	:	05/05/2020

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