Provider Demographics
NPI:1740859461
Name:PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC
Entity type:Organization
Organization Name:PORT CHARLOTTE HMA PHYSICIAN MANAGEMENT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR DR PROV ENROLLMENT & ONLOADING
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 1:713 E MARION AVE STE 139
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3863
Practice Address - Country:US
Practice Address - Phone:941-833-1760
Practice Address - Fax:941-205-3374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid