Provider Demographics
| NPI: | 1740852698 |
|---|---|
| Name: | COLLIER BOULEVARD HMA PHYSICIAN MANAGEMENT LLC |
| Entity type: | Organization |
| Organization Name: | COLLIER BOULEVARD HMA PHYSICIAN MANAGEMENT LLC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | SR DIR PROV ENROLLMENT & ONBOARDING |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | JENNIFER |
| Authorized Official - Middle Name: | L |
| Authorized Official - Last Name: | JACKSON |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 615-465-3334 |
| Mailing Address - Street 1: | PO BOX 689022 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | FRANKLIN |
| Mailing Address - State: | TN |
| Mailing Address - Zip Code: | 37068-9022 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 615-465-7211 |
| Mailing Address - Fax: | 615-628-6877 |
| Practice Address - Street 1: | 8340 COLLIER BLVD STE 201 |
| Practice Address - Street 2: | |
| Practice Address - City: | NAPLES |
| Practice Address - State: | FL |
| Practice Address - Zip Code: | 34114-3589 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 239-348-4448 |
| Practice Address - Fax: | 239-732-0639 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2021-07-12 |
| Last Update Date: | 2022-03-14 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty | |
| No | 207QG0300X | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | Group - Single Specialty |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Single Specialty | |
| No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Single Specialty |
| No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Single Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Single Specialty | |
| No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Single Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Single Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Single Specialty | |
| No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Single Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Single Specialty | |
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Single Specialty |
| No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Single Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Single Specialty | |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Single Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| FL | 001609611 | Medicaid |
