Provider Demographics
NPI:1588749618
Name:SOUTHWEST FLORIDA FERTILITY CENTER PA
Entity type:Organization
Organization Name:SOUTHWEST FLORIDA FERTILITY CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:GLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL DOCTOR MD
Authorized Official - Phone:239-561-3430
Mailing Address - Street 1:15730 NEW HAMPSHIRE CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908
Mailing Address - Country:US
Mailing Address - Phone:239-561-3430
Mailing Address - Fax:239-561-6980
Practice Address - Street 1:15730 NEW HAMPSHIRE CT
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-561-3430
Practice Address - Fax:239-561-6980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0057264207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0057264OtherFLORIDA STATE LICENSE
FL379285400Medicaid
F40373Medicare UPIN
FL379285400Medicaid
FLME0057264OtherFLORIDA STATE LICENSE