Provider Demographics
NPI:1700463643
Name:AXEL HEALTH PRIMARY CARE LLC
Entity Type:Organization
Organization Name:AXEL HEALTH PRIMARY CARE LLC
Other - Org Name:LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUMEET
Authorized Official - Middle Name:
Authorized Official - Last Name:SHETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-208-6648
Mailing Address - Street 1:6811 PORTO FINO CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4354
Mailing Address - Country:US
Mailing Address - Phone:239-208-6648
Mailing Address - Fax:239-931-0221
Practice Address - Street 1:6811 PORTO FINO CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4354
Practice Address - Country:US
Practice Address - Phone:239-208-6648
Practice Address - Fax:239-931-0221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-26
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME91067OtherMEDICAL LICENSE