Provider Demographics
NPI:1730672379
Name:PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC
Entity Type:Organization
Organization Name:PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC
Other - Org Name:SHOREPOINT OBSTETRICS AND GYNECOLOGY- RHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1012 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-8811
Practice Address - Country:US
Practice Address - Phone:941-766-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-08
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health