Provider Demographics
NPI:1629487954
Name:LINEBERRY, CASEY (PA)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:LINEBERRY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:842 SUNSET LAKE BLVD
Practice Address - Street 2:SUITE 403, BLDG. B
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-7551
Practice Address - Country:US
Practice Address - Phone:941-684-3216
Practice Address - Fax:941-485-7677
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108085363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL398592OtherAVMED
FLP01374271OtherRR MEDICARE
FLP1020766OtherFREEDOM
FL1225577OtherWELLCARE
FLP959325OtherOPTIMUM
FL1666744OtherCIGNA
FLY0N2UOtherBCBS
FL5924852OtherAETNA
FLHX364ZMedicare PIN
FLHX364YMedicare PIN