Provider Demographics
NPI:1851580740
Name:COLLIER OTOLARYNGOLOGY-HEAD AND NECK SURGERY PA
Entity Type:Organization
Organization Name:COLLIER OTOLARYNGOLOGY-HEAD AND NECK SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-592-9666
Mailing Address - Street 1:1879 VETERANS PARK DR
Mailing Address - Street 2:SUITE 1201
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34109-0492
Mailing Address - Country:US
Mailing Address - Phone:239-592-9666
Mailing Address - Fax:239-592-1835
Practice Address - Street 1:1879 VETERANS PARK DR
Practice Address - Street 2:SUITE 1201
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0492
Practice Address - Country:US
Practice Address - Phone:239-262-6668
Practice Address - Fax:239-262-0017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0063724174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1003OtherMEDICARE PTAN