Provider Demographics
NPI:1972210102
Name:PANIRA HEALTHCARE CLINIC, INC,
Entity type:Organization
Organization Name:PANIRA HEALTHCARE CLINIC, INC,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:GENEVE
Authorized Official - Last Name:MONGENE-EGGER
Authorized Official - Suffix:
Authorized Official - Credentials:RN/BSN
Authorized Official - Phone:239-529-5580
Mailing Address - Street 1:4975 TAMIAMI TRL E
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34113-4131
Mailing Address - Country:US
Mailing Address - Phone:239-529-5580
Mailing Address - Fax:239-280-0264
Practice Address - Street 1:4975 TAMIAMI TRL E
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34113-4131
Practice Address - Country:US
Practice Address - Phone:239-529-5580
Practice Address - Fax:239-280-0264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021195500Medicaid