Provider Demographics
NPI:1295700193
Name:PERSONALIZED PHYSICIAN CARE, LLC
Entity type:Organization
Organization Name:PERSONALIZED PHYSICIAN CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DARSTEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-596-1111
Mailing Address - Street 1:9655 TAMIAMI TRL N
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-2796
Mailing Address - Country:US
Mailing Address - Phone:239-596-1111
Mailing Address - Fax:239-596-1659
Practice Address - Street 1:9655 TAMIAMI TRL N
Practice Address - Street 2:SUITE 102
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-2796
Practice Address - Country:US
Practice Address - Phone:239-596-1111
Practice Address - Fax:239-596-1659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2743Medicare UPIN