Provider Demographics
NPI:1427291673
Name:PORT CHARLOTTE HMA PHYSICIAN MGMT LLC
Entity type:Organization
Organization Name:PORT CHARLOTTE HMA PHYSICIAN MGMT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR PROVIDER ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:5811 PELICAN BAY BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-2704
Mailing Address - Country:US
Mailing Address - Phone:239-598-3131
Mailing Address - Fax:239-598-9433
Practice Address - Street 1:3067 TAMIAMI TRL
Practice Address - Street 2:UNIT 1
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6601
Practice Address - Country:US
Practice Address - Phone:941-258-3575
Practice Address - Fax:941-258-3584
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTH MANAGEMENT ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-16
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AE561Medicare PIN