Provider Demographics
NPI:1407812092
Name:ATLANTIC UROLOGICAL ASSOCIATES P A
Entity Type:Organization
Organization Name:ATLANTIC UROLOGICAL ASSOCIATES P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:CREGGAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-239-8500
Mailing Address - Street 1:545 HEALTH BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1493
Mailing Address - Country:US
Mailing Address - Phone:386-239-8500
Mailing Address - Fax:386-239-8530
Practice Address - Street 1:545 HEALTH BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1493
Practice Address - Country:US
Practice Address - Phone:386-239-8500
Practice Address - Fax:386-239-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1900147OtherUNITED HEALTHCARE
FL037142400Medicaid
FL99107OtherBLUE SHIELD
K0094Medicare ID - Type Unspecified