# COLLIER BOULEVARD HMA PHYSICIAN MANAGEMENT LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Collier Boulevard HMA Physician Management LLC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1710555818
- **Authorized official:** JENNIFER L JACKSON (SR DIR PROV ENROLLMENT & ONBOARDING)
- **Authorized official phone:** (615) 465-3334

## Contact information

- **Practice address:** 24231 WALDEN CENTER DR STE 160, ESTERO, FL 34134-5011
- **Practice address phone:** (239) 348-4221
- **Practice address fax:** (239) 348-4529
- **Mailing address:** PO BOX 689022, FRANKLIN, TN 37068-9022
- **Mailing address phone:** (615) 465-7211
- **Mailing address fax:** (615) 628-6877

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | — | — | Yes |
| 363L00000X | Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 06/15/2021
- **Last updated:** 03/14/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 001609630 | — | FL |