Provider Demographics
NPI:1427203348
Name:ATLANTIC ENT LLC
Entity Type:Organization
Organization Name:ATLANTIC ENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:WIDICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-799-9797
Mailing Address - Street 1:333 W COCOA BEACH CSWY STE B
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-3513
Mailing Address - Country:US
Mailing Address - Phone:321-799-9797
Mailing Address - Fax:
Practice Address - Street 1:333 W COCOA BEACH CSWY STE B
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3513
Practice Address - Country:US
Practice Address - Phone:321-799-9797
Practice Address - Fax:321-799-3393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0061454207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06456Medicare PIN
FLH53063Medicare UPIN