Basic Information
Provider Information | |||||||||
NPI: | 1841590965 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICIANS REGIONAL MEDICAL CENTER - COLLIER BLVD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 26309 | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336236309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138996226 | ||||||||
FaxNumber: | 8139858006 | ||||||||
Practice Location | |||||||||
Address1: | 8300 COLLIER BLVD | ||||||||
Address2: |   | ||||||||
City: | NAPLES | ||||||||
State: | FL | ||||||||
PostalCode: | 341143549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138996226 | ||||||||
FaxNumber: | 8139858006 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/22/2010 | ||||||||
LastUpdateDate: | 10/22/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NORSOPH | ||||||||
AuthorizedOfficialFirstName: | ELLIS | ||||||||
AuthorizedOfficialMiddleName: | B. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8138996220 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0200X | 4463 | FL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
ID Information
ID | Type | State | Issuer | Description | 4463 | 01 | FL | STATE LICENSE | OTHER |