Provider Demographics
NPI:1720020852
Name:HACKMAN-KERBYSON, ELEONORA (MD)
Entity Type:Individual
Prefix:
First Name:ELEONORA
Middle Name:
Last Name:HACKMAN-KERBYSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELEONORA
Other - Middle Name:
Other - Last Name:HACKMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3434 HANCOCK BRIDGE PKWY
Mailing Address - Street 2:STE 301
Mailing Address - City:N FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7094
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2625
Practice Address - Street 1:2450 TAMIAMI TRL
Practice Address - Street 2:STE A
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-3922
Practice Address - Country:US
Practice Address - Phone:941-624-2704
Practice Address - Fax:941-627-6066
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003014738207P00000X
IL036-110911207P00000X
FLME104987207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO426403OtherHEALTHLINK
MO124884OtherBLUE CROSS
MO208440818Medicaid
MO947071631OtherMERCY HEALTH
MOP00145175OtherRAILROAD MEDICARE
IL036110911Medicaid
MO124884OtherBLUE CROSS
FLCL509WMedicare PIN
MO947071631OtherMERCY HEALTH
IL036110911Medicaid
MO919451631Medicare PIN
IL214881018Medicare PIN