Basic Information
| Provider Information | |||||||||
| NPI: | 1386700375 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLLIER HMA PHYSICIAN MANAGMENT, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 277575 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303847575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663916826 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1845 SAN MARCO RD | ||||||||
| Address2: | UNIT 203 | ||||||||
| City: | MARCO ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341456722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393484400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR DIR PROV ENROLLMENT & ONBOARDING | ||||||||
| AuthorizedOfficialTelephone: | 6154653334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 275883103 | 05 | FL | MEDICAID |