Provider Demographics
NPI:1619940582
Name:FT MYERS DIGESTIVE HEALTH AND PAIN ASC LLC
Entity Type:Organization
Organization Name:FT MYERS DIGESTIVE HEALTH AND PAIN ASC LLC
Other - Org Name:CENTER FOR DIGESTIVE HEALTH AND PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:12700 CREEKSIDE LN
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3356
Mailing Address - Country:US
Mailing Address - Phone:239-489-1660
Mailing Address - Fax:239-489-2114
Practice Address - Street 1:12700 CREEKSIDE LN
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3356
Practice Address - Country:US
Practice Address - Phone:239-489-1660
Practice Address - Fax:239-489-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL776261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0751839-00Medicaid
FL=========OtherPALMETTO GBA-TRICARE
FL0751839-00Medicaid
FL=========OtherPALMETTO GBA-TRICARE
FL490005255Medicare PIN