Provider Demographics
NPI:1902425028
Name:LEE MEMORIAL HEALTH SYSTEM
Entity Type:Organization
Organization Name:LEE MEMORIAL HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEBERGALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-424-1446
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:941-629-2922
Mailing Address - Fax:941-629-1311
Practice Address - Street 1:2525 HARBOR BLVD STE 204
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5342
Practice Address - Country:US
Practice Address - Phone:941-629-2922
Practice Address - Fax:941-629-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)