Provider Demographics
NPI:1326021239
Name:PHYSICIANS PRIMARY CARE OF SOUTHWEST FLORIDA PL
Entity Type:Organization
Organization Name:PHYSICIANS PRIMARY CARE OF SOUTHWEST FLORIDA PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:YANKASKAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-275-5522
Mailing Address - Street 1:12730 NEW BRITTANY BLVD STE 602
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4690
Mailing Address - Country:US
Mailing Address - Phone:239-275-5522
Mailing Address - Fax:239-275-4464
Practice Address - Street 1:1261 VISCAYA PKWY STE 101
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3252
Practice Address - Country:US
Practice Address - Phone:239-573-7337
Practice Address - Fax:239-574-5883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379245514Medicaid
FL379245514Medicaid