Basic Information
| Provider Information | |||||||||
| NPI: | 1720020852 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HACKMAN-KERBYSON | ||||||||
| FirstName: | ELEONORA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HACKMAN | ||||||||
| OtherFirstName: | ELEONORA | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3434 HANCOCK BRIDGE PKWY | ||||||||
| Address2: | STE 301 | ||||||||
| City: | N FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339037094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 2395992625 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 TAMIAMI TRL | ||||||||
| Address2: | STE A | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339523922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416242704 | ||||||||
| FaxNumber: | 9416276066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 02/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2003014738 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036-110911 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | ME104987 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 426403 | 01 | MO | HEALTHLINK | OTHER | 124884 | 01 | MO | BLUE CROSS | OTHER | 208440818 | 05 | MO | MEDICAID | 947071631 | 01 | MO | MERCY HEALTH | OTHER | P00145175 | 01 | MO | RAILROAD MEDICARE | OTHER | 036110911 | 05 | IL | MEDICAID |