| Entity Name: | COLLIER PODIATRY, P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 31 May 2002 (23 years ago) |
| Document Number: | P02000060650 |
| FEI/EIN Number | 010733526 |
| Address: | 1715 HERITAGE TRAIL, SUITE 204, NAPLES, FL, 34112, US |
| Mail Address: | 1715 HERITAGE TRAIL, SUITE 204, NAPLES, FL, 34112, US |
| ZIP code: | 34112 |
| County: | Collier |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1164634556 | 2007-05-06 | 2023-03-07 | 1715 HERITAGE TRL, SUITE 204, NAPLES, FL, 341128715, US | 1715 HERITAGE TRL, SUITE 204, NAPLES, FL, 341128715, US | |||||||||||||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 239-775-0019 |
| Fax | 2397750219 |
Authorized person
| Name | DR. MICHAEL JOHN PETROCELLI |
| Role | PRESIDENT |
| Phone | 2397750019 |
Taxonomy
| Taxonomy Code | 213ES0131X - Foot Surgery Podiatrist |
| License Number | PO-2399 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | NPI PERSONAL NUMBER |
| Number | 1811988165 |
| Issuer | AETNA NUMBER |
| Number | 4574474 |
| State | FL |
| Issuer | STATE LICENSE NUMBER |
| Number | PO-2399 |
| State | FL |
| Issuer | BCBS NUMBER |
| Number | 65356A |
| State | FL |
| Issuer | MEDICAID |
| Number | 340308400 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| PETROCELLI MICHAEL J | Agent | 1715 HERITAGE TRAIL, SUITE 204, NAPLES, FL, 34112 |
| Name | Role | Address |
|---|---|---|
| PETROCELLI MICHAEL J | Director | 1715 HERITAGE TRAIL, SUITE 204, NAPLES, FL, 34112 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2011-01-16 | 1715 HERITAGE TRAIL, SUITE 204, NAPLES, FL 34112 | No data |
| CHANGE OF MAILING ADDRESS | 2011-01-16 | 1715 HERITAGE TRAIL, SUITE 204, NAPLES, FL 34112 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2002-09-23 | 1715 HERITAGE TRAIL, SUITE 204, NAPLES, FL 34112 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-21 |
| ANNUAL REPORT | 2024-01-14 |
| ANNUAL REPORT | 2023-01-18 |
| ANNUAL REPORT | 2022-02-01 |
| ANNUAL REPORT | 2021-01-12 |
| ANNUAL REPORT | 2020-03-22 |
| ANNUAL REPORT | 2019-02-11 |
| ANNUAL REPORT | 2018-04-03 |
| ANNUAL REPORT | 2017-01-10 |
| ANNUAL REPORT | 2016-02-28 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
