Basic Information
Provider Information | |||||||||
NPI: | 1679591275 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TOLEP | ||||||||
FirstName: | KENNETH | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2234 COLONIAL BLVD | ||||||||
Address2: | ATTN: PAYER CONTRACTING & RELATIONS | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339071412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2399317342 | ||||||||
FaxNumber: | 2399317385 | ||||||||
Practice Location | |||||||||
Address1: | 7335 GLADIOLUS DR | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339085101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2399851925 | ||||||||
FaxNumber: | 2393216044 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 07/28/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | ME0071219 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 32365 | 01 | FL | BCBS OF FL | OTHER | 9292481 | 01 | FL | CIGNA | OTHER | 231195 | 01 | FL | AVMED | OTHER | P01319833 | 01 | FL | RR MEDICARE | OTHER | P203275 | 01 | FL | OPTIMUM | OTHER | 251046400 | 05 | FL |   | MEDICAID | P107184 | 01 | FL | FREEDOM | OTHER | 4202982 | 01 | FL | AETNA | OTHER |