Provider Demographics
NPI:1417957325
Name:ATLANTIS CLINIC PA
Entity Type:Organization
Organization Name:ATLANTIS CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:CHIPMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:813-891-6343
Mailing Address - Street 1:3705 TAMPA RD. SUITE 22
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-6346
Mailing Address - Country:US
Mailing Address - Phone:813-891-6343
Mailing Address - Fax:813-891-6342
Practice Address - Street 1:3705 TAMPA RD
Practice Address - Street 2:#22
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-6300
Practice Address - Country:US
Practice Address - Phone:813-891-6343
Practice Address - Fax:813-891-6342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257635000Medicaid
FL257635000Medicaid