Provider Demographics
NPI:1639320153
Name:ATLANTIC FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:ATLANTIC FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ONGSIAKO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-505-9333
Mailing Address - Street 1:1228 ROUTE 37 W
Mailing Address - Street 2:SUITE 6
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-4811
Mailing Address - Country:US
Mailing Address - Phone:732-505-9333
Mailing Address - Fax:732-505-9980
Practice Address - Street 1:1228 ROUTE 37 W
Practice Address - Street 2:SUITE 6
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-4811
Practice Address - Country:US
Practice Address - Phone:732-505-9333
Practice Address - Fax:732-505-9980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05884600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ071830OtherMEDICARE ID
193873Medicare PIN
NJ071830OtherMEDICARE ID