Provider Demographics
NPI:1255674438
Name:PHYSICIAN'S MANAGED SERVICES ORGANIZATION OF SOUTHWEST FLORIDA, LLC
Entity type:Organization
Organization Name:PHYSICIAN'S MANAGED SERVICES ORGANIZATION OF SOUTHWEST FLORIDA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:BECKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-514-3131
Mailing Address - Street 1:1200 CORPORATE CENTER WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-2108
Mailing Address - Country:US
Mailing Address - Phone:561-623-8300
Mailing Address - Fax:
Practice Address - Street 1:1890 SW HEALTH PKWY
Practice Address - Street 2:SUITE 203
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-0473
Practice Address - Country:US
Practice Address - Phone:239-514-3131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-05
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58884207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008754000Medicaid
FL004UROtherBCBSFL