MEDICARE: PORT CHARLOTTE HMA 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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1972890069
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORT CHARLOTTE HMA 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	:	3067 TAMIAMI TRL
Second Line	:	UNITE 1
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-6619
Country	:	US
Telephone Number	:	941-766-0400
Fax Number	:	941-766-1009

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

Provider Enumeration Date	:	07/08/2011
Last Update Date	:	03/18/2022

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