Basic Information
| Provider Information | |||||||||
| NPI: | 1134133416 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED MEDICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 PINE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341088913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395667676 | ||||||||
| FaxNumber: | 2392543105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 PINE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341088913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395667676 | ||||||||
| FaxNumber: | 2392543105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 01/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | LEACH | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2395667676 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME42024 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.