Provider Demographics
NPI:1487788824
Name:ATLANTIC ORTHOPAEDICS, PA
Entity type:Organization
Organization Name:ATLANTIC ORTHOPAEDICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-760-0915
Mailing Address - Street 1:1400 DUNLAWTON AVE STE 1-A
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8952
Mailing Address - Country:US
Mailing Address - Phone:386-760-0915
Mailing Address - Fax:386-760-0084
Practice Address - Street 1:1020 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117
Practice Address - Country:US
Practice Address - Phone:386-760-0915
Practice Address - Fax:386-760-0084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0044566207X00000X
FLME0027133207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0027133OtherLISCENSE
FLME0044566OtherLISCENSE
FLME0027133OtherLISCENSE
FLME0044566OtherLISCENSE
FLD57645Medicare UPIN
FLD78862Medicare UPIN