Provider Demographics
NPI:1447201660
Name:SIEVERT CLINIC, LLC
Entity Type:Organization
Organization Name:SIEVERT CLINIC, LLC
Other - Org Name:SIEVERT CLINIC & WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:SIEVERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-936-1233
Mailing Address - Street 1:3880 COLONIAL BLVD
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1062
Mailing Address - Country:US
Mailing Address - Phone:239-936-1233
Mailing Address - Fax:239-936-8576
Practice Address - Street 1:3880 COLONIAL BLVD
Practice Address - Street 2:SUITE 1A
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1062
Practice Address - Country:US
Practice Address - Phone:239-936-1233
Practice Address - Fax:239-936-8576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3599111N00000X
FLOS9565207Q00000X
FLARNP2826072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77550OtherBLUE CROSS BLUE SHIELD
FLU21337Medicare UPIN
FLCY810AMedicare PIN
FL77550OtherBLUE CROSS BLUE SHIELD