Provider Demographics
NPI:1750040598
Name:PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC
Entity Type:Organization
Organization Name:PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC
Other - Org Name:PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIR ONBOARDING & PROV 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:615-465-7211
Mailing Address - Fax:877-892-9815
Practice Address - Street 1:713 E MARION AVE STE 121
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3862
Practice Address - Country:US
Practice Address - Phone:941-833-1760
Practice Address - Fax:941-205-3374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-09
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278507222Medicaid