Provider Demographics
NPI:1376704155
Name:ATLANTIC NEPHROLOGY INC
Entity Type:Organization
Organization Name:ATLANTIC NEPHROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BONLORE
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:386-871-3767
Mailing Address - Street 1:61 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:SUITE #3806
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5981
Mailing Address - Country:US
Mailing Address - Phone:386-437-7340
Mailing Address - Fax:
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:SUITE #3806
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5981
Practice Address - Country:US
Practice Address - Phone:386-437-7340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94793207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250792700Medicaid
FL40336OtherMEDICARE NUMBER
FLAD824ZOtherPTAN