Provider Demographics
NPI:1437209855
Name:FT MYERS PHYSICIAN PA
Entity Type:Organization
Organization Name:FT MYERS PHYSICIAN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:KILLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-333-0084
Mailing Address - Street 1:2721 DEL PRADO BLVD S
Mailing Address - Street 2:SUITE 240
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-5781
Mailing Address - Country:US
Mailing Address - Phone:239-333-0084
Mailing Address - Fax:239-333-0086
Practice Address - Street 1:2721 DEL PRADO BLVD S
Practice Address - Street 2:SUITE 240
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-5781
Practice Address - Country:US
Practice Address - Phone:239-333-0084
Practice Address - Fax:239-333-0086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36712207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID
FL=========OtherTAX ID
FL39207Medicare PIN