Provider Demographics
NPI:1144635426
Name:GEORGE P. FITZGERALD III MD
Entity type:Organization
Organization Name:GEORGE P. FITZGERALD III MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JERI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KSIAZEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-334-8888
Mailing Address - Street 1:3594 BROADWAY AVENUE
Mailing Address - Street 2:SUITE E
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8017
Mailing Address - Country:US
Mailing Address - Phone:239-334-8888
Mailing Address - Fax:239-334-9534
Practice Address - Street 1:3594 BROADWAY
Practice Address - Street 2:SUITE E
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8016
Practice Address - Country:US
Practice Address - Phone:239-334-8888
Practice Address - Fax:239-334-9534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0020292207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty