MEDICARE: PORT CHARLOTTE HMA PHYSICIAN MGMT 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	207P00000X	Emergency Medicine Physician

General Provider Information

NPI Number	:	1427291673
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT CHARLOTTE HMA PHYSICIAN MGMT LLC

Provider Business Mailing Address
First Line	:	5811 PELICAN BAY BLVD
Second Line	:	SUITE 500
City	:	NAPLES
State	:	FL
Zip	:	34108-2704
Country	:	US
Telephone Number	:	239-598-3131
Fax Number	:	239-598-9433

Provider Business Practice Location Address
First Line	:	3067 TAMIAMI TRL
Second Line	:	UNIT 1
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-6601
Country	:	US
Telephone Number	:	941-258-3575
Fax Number	:	941-258-3584

Authorized Official
Title or Position	:	SENIOR DIRECTOR PROVIDER ENROLLMENT
Name	:	MS. JENNY JACKSON
Credential	:
Telephone Number	:	615-465-3334

Provider Enumeration Date	:	04/16/2009
Last Update Date	:	03/18/2022

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