Basic Information
| Provider Information | |||||||||
| NPI: | 1316904022 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENTALERI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 WINKLER AVE | ||||||||
| Address2: | FL 2 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339019342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8448218137 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 PHILLIPS RD | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323085304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508784127 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME78641 | FL | N | Other Service Providers | Specialist | 2085R0202X | ME78641 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 301630 | 01 | FL | AVMED | OTHER | P00301196 | 01 | FL | MEDICARE RAILROAD | OTHER | 003156073A | 01 | GA | GA MEDICAID | OTHER | 259013100 | 05 | FL | MEDICAID | 35376 | 01 | FL | BCBS | OTHER | P01130437 | 01 | FL | RR MEDICARE | OTHER |