MEDICARE: PHOENIX MEDICAL LABORATORY

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	291U00000X	Clinical Medical Laboratory	8000017185	FL
2	291U00000X	Clinical Medical Laboratory	CLIA10D1023653	FL
3	291U00000X	Clinical Medical Laboratory	8000019289	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	L9266	OTHER	FL	BCBS FL

General Provider Information

NPI Number	:	1841280815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX MEDICAL LABORATORY

Provider Business Mailing Address
First Line	:	12701 COMMONWEALTH DR
Second Line	:	SUITE 6
City	:	FORT MYERS
State	:	FL
Zip	:	33913-8626
Country	:	US
Telephone Number	:	239-768-0600
Fax Number	:	239-768-0711

Provider Business Practice Location Address
First Line	:	12701 COMMONWEALTH DR
Second Line	:	SUITE 6
City	:	FORT MYERS
State	:	FL
Zip	:	33913-8626
Country	:	US
Telephone Number	:	239-768-0600
Fax Number	:	239-768-0711

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ROBERT P GASPARINI
Credential	:
Telephone Number	:	239-768-0600

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	05/29/2008

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