Provider Demographics
NPI:1518976661
Name:ATLANTIC SURGERY CENTER INC
Entity Type:Organization
Organization Name:ATLANTIC SURGERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CANTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-239-0021
Mailing Address - Street 1:541 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:386-239-0021
Mailing Address - Fax:386-248-8226
Practice Address - Street 1:541 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:386-239-0021
Practice Address - Fax:386-248-8226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1020261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1495361OtherUNITED MINE WORKERS
FL006574700Medicaid
FL64JOtherBLUE CROSS AND BLUE SHIEL
FL1495361OtherUNITED MINE WORKERS
FLF1218Medicare ID - Type UnspecifiedMEDICARE