MEDICARE: ST CLOUD PHYSICIAN MANAGEMENT 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1669777264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST CLOUD PHYSICIAN MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	5811 PELICAN BAY BLVD
Second Line	:	SUITE 500
City	:	NAPLES
State	:	FL
Zip	:	34108-2733
Country	:	US
Telephone Number	:	239-598-3131
Fax Number	:	239-592-0438

Provider Business Practice Location Address
First Line	:	1931 S NARCOOSSEE RD
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34771-7211
Country	:	US
Telephone Number	:	407-891-0045
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. MICHAEL L GINGRAS
Credential	:
Telephone Number	:	239-598-3131

Provider Enumeration Date	:	01/13/2011
Last Update Date	:	11/27/2012

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