Provider Demographics
NPI:1467649764
Name:ATLANTIC UROLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ATLANTIC UROLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-595-5977
Mailing Address - Street 1:701 E 28TH ST
Mailing Address - Street 2:SUITE 319
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2759
Mailing Address - Country:US
Mailing Address - Phone:562-595-5977
Mailing Address - Fax:562-490-0509
Practice Address - Street 1:701 E 28TH ST
Practice Address - Street 2:SUITE 319
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2759
Practice Address - Country:US
Practice Address - Phone:562-595-5977
Practice Address - Fax:562-490-0509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32052174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2405716Medicaid
CAW9927OtherMEDICARE ID
CA2405716Medicaid