Basic Information
| Provider Information | |||||||||
| NPI: | 1184707689 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLIER HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MARION E FETHER MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1454 MADISON AVE W | ||||||||
| Address2: | |||||||||
| City: | IMMOKALEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341422200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583000 | ||||||||
| FaxNumber: | 2396583063 | ||||||||
| Practice Location | |||||||||
| Address1: | 1454 MADISON AVE W | ||||||||
| Address2: | |||||||||
| City: | IMMOKALEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341422200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583000 | ||||||||
| FaxNumber: | 2396583063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 06/01/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STEELE-RIORDAN | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2396583003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | PH6822 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 5133530001 | 01 | FL | DME MEDICARE | OTHER | 102892801 | 05 | FL | MEDICAID | BC1757535 | 01 | FL | DEA | OTHER | 1031563 | 01 | FL | NABP | OTHER |