MEDICARE: DR. STEPHEN A PRENDIVILLE M.D.

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	174400000X	Specialist	ME81906	FL

General Provider Information

NPI Number	:	1558309054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN A PRENDIVILLE M.D.

Provider Business Mailing Address
First Line	:	9407 CYPRESS LAKE DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-0910
Country	:	US
Telephone Number	:	239-437-3900
Fax Number	:	239-437-3969

Provider Business Practice Location Address
First Line	:	9407 CYPRESS LAKE DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-0910
Country	:	US
Telephone Number	:	239-437-3900
Fax Number	:	239-437-3969

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	10/06/2008

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