# MEDICAL CENTRE OF FORT MYERS

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1356003081
- **Authorized official:** DEMETRIS WEAVER PRESIDENT (PRESIDENT)
- **Authorized official phone:** (813) 252-6114

## Contact information

- **Practice address:** 4901 PALM BEACH BLVD STE 101, FORT MYERS, FL 33905-3252
- **Practice address phone:** (813) 252-6114
- **Mailing address:** 4901 PALM BEACH BLVD STE 101, FORT MYERS, FL 33905-3252
- **Mailing address phone:** (813) 252-6114

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 103T00000X | Psychologist | — | — | — |
| 2084P0802X | Addiction Psychiatry Physician | — | — | — |
| 208D00000X | General Practice Physician | — | — | Yes |
| 261Q00000X | Clinic/Center | — | — | — |
| 261QM0801X | Mental Health Clinic/Center (Including Community Mental Health Center) | — | — | — |
| 261QM0850X | Adult Mental Health Clinic/Center | — | — | — |
| 261QM2800X | Methadone Clinic | — | — | — |
| 261QP2300X | Primary Care Clinic/Center | — | — | — |

## Other

- **Enumeration date:** 10/11/2021
- **Last updated:** 10/20/2021