Provider Demographics
NPI:1639226608
Name:LEE COUNTY TRAUMA SERVICES DISTRICT
Entity Type:Organization
Organization Name:LEE COUNTY TRAUMA SERVICES DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT,CEO
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-343-6537
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1500
Mailing Address - Fax:239-424-1423
Practice Address - Street 1:13685 DOCTORS WAY STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4337
Practice Address - Country:US
Practice Address - Phone:239-343-1612
Practice Address - Fax:239-343-4229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268529900Medicaid
FL268529900Medicaid