Provider Demographics
NPI:1619123312
Name:ATIT NEUROLOGY PA
Entity Type:Organization
Organization Name:ATIT NEUROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:CPAM,MA
Authorized Official - Phone:727-937-4600
Mailing Address - Street 1:1011 US HIGHWAY 19
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34691-5636
Mailing Address - Country:US
Mailing Address - Phone:727-937-4600
Mailing Address - Fax:727-937-3312
Practice Address - Street 1:1011 US HIGHWAY 19
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34691-5636
Practice Address - Country:US
Practice Address - Phone:727-937-4600
Practice Address - Fax:727-937-3312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071634174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271853700Medicaid
FLAM861Medicare PIN
FLG86849Medicare UPIN