Basic Information
| Provider Information | |||||||||
| NPI: | 1295802445 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLLIER HMA PHYSICIAN MANAGEMENT, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5811 PELICAN BAY BLVD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341082704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2395983131 | ||||||||
| FaxNumber: | 2395989433 | ||||||||
| Practice Location | |||||||||
| Address1: | 8340 COLLIER BOULEVARD | ||||||||
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| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393484400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 06/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | MCLEMORE | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2395983131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH MANAGEMENT ASSOCIATES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 275883100 | 05 | FL | MEDICAID |