1144281247 NPI number — ATLANTIC MEDICAL GROUP

Table of content: (NPI 1144281247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144281247 NPI number — ATLANTIC MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTIC MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144281247
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1541 S WICKHAM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32904-3540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-726-6331
Provider Business Mailing Address Fax Number:
321-726-6371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1541 S WICKHAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32904-3540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-726-6331
Provider Business Practice Location Address Fax Number:
321-726-6371
Provider Enumeration Date:
03/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROQUE
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
321-726-6331

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME88828 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 159351XX . This is a "PREFERRED CARE PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 37972 . This is a "BCBS PROVIDER ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1809978 . This is a "FIRST HEALTH PROVIDER NO." identifier . This identifiers is of the category "OTHER".
  • Identifier: 9303692 . This is a "CIGNA PROVIDER NO." identifier . This identifiers is of the category "OTHER".
  • Identifier: DD4702 . This is a "RAILROAD MCARE GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00022983 . This is a "RAILROAD MCARE PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 246370 . This is a "WELLCARE MCAID PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5585831 . This is a "CCN NETWORK PROVIDER NO." identifier . This identifiers is of the category "OTHER".
  • Identifier: 7274610 . This is a "AETNA PROVIDER NO." identifier . This identifiers is of the category "OTHER".
  • Identifier: 10024 . This is a "FLORIDIANCARE PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9362860 . This is a "PHCS PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 024915300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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