Provider Demographics
NPI:1104259035
Name:PHYSICIANS MEDICAL GROUP OF SOUTHWEST FLORIDA,LLC
Entity type:Organization
Organization Name:PHYSICIANS MEDICAL GROUP OF SOUTHWEST FLORIDA,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-936-1233
Mailing Address - Street 1:3800 COLONIAL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1075
Mailing Address - Country:US
Mailing Address - Phone:239-936-1233
Mailing Address - Fax:239-936-8576
Practice Address - Street 1:3800 COLONIAL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1075
Practice Address - Country:US
Practice Address - Phone:239-936-1233
Practice Address - Fax:239-936-8576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-14
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS002373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty