MEDICARE: PEDIATRIC ENT OF SOUTHWEST FLORIDA PLLC

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	207YP0228X	Pediatric Otolaryngology Physician

General Provider Information

NPI Number	:	1619389962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC ENT OF SOUTHWEST FLORIDA PLLC

Provider Business Mailing Address
First Line	:	19 GEORGETOWN
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-1088
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19 GEORGETOWN
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-1088
Country	:	US
Telephone Number	:	210-216-5650
Fax Number	:

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	DOUGLAS J GOTTSCHALK
Credential	:
Telephone Number	:	210-216-5650

Provider Enumeration Date	:	05/21/2014
Last Update Date	:	05/21/2014

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