Provider Demographics
NPI:1255436143
Name:FORT MYERS FAMILY MEDICINE LLC
Entity type:Organization
Organization Name:FORT MYERS FAMILY MEDICINE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MANAGING DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HURSEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ADKINS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:239-433-4014
Mailing Address - Street 1:15661 SAN CARLOS BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-2797
Mailing Address - Country:US
Mailing Address - Phone:239-433-4014
Mailing Address - Fax:239-481-6247
Practice Address - Street 1:15661 SAN CARLOS BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-433-4014
Practice Address - Fax:239-481-6247
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORT MYERS FAMILY MEDICINE PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-14
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0005720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268237100Medicaid
FLK1484OtherMEDICARE PTAN
FLK1484OtherMEDICARE PTAN