Provider Demographics
NPI:1376664565
Name:INJURY TREATMENT CENTER OF FORT MYERS INC
Entity Type:Organization
Organization Name:INJURY TREATMENT CENTER OF FORT MYERS INC
Other - Org Name:CHOICE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-817-9402
Mailing Address - Street 1:2295 NW CORPORATE BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-7373
Mailing Address - Country:US
Mailing Address - Phone:561-241-1971
Mailing Address - Fax:561-241-3969
Practice Address - Street 1:8595 COLLEGE PKWY
Practice Address - Street 2:SUITE A2
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-5191
Practice Address - Country:US
Practice Address - Phone:239-489-2290
Practice Address - Fax:239-482-6028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC6084208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00802OtherBLUE SHIELD NUMBER
FL00802OtherBLUE SHIELD NUMBER