Provider Demographics
NPI: | 1023544012 |
---|---|
Name: | HALL, JAIME MARIE REALSEN (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JAIME |
Middle Name: | MARIE REALSEN |
Last Name: | HALL |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | JAIME |
Other - Middle Name: | MARIE |
Other - Last Name: | REALSEN |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | PO BOX 2147 |
Mailing Address - Street 2: | |
Mailing Address - City: | FORT MYERS |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33902-2147 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 239-343-1100 |
Mailing Address - Fax: | 239-343-1101 |
Practice Address - Street 1: | 13782 PLANTATION RD STE 201 |
Practice Address - Street 2: | |
Practice Address - City: | FORT MYERS |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33912-4462 |
Practice Address - Country: | US |
Practice Address - Phone: | 239-343-1100 |
Practice Address - Fax: | 239-343-1101 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2017-05-11 |
Last Update Date: | 2023-07-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
390200000X | ||
FL | ME142894 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 104838200 | Medicaid |