Provider Demographics
NPI:1730103086
Name:ATLANTIC SPACE COAST GI PA
Entity Type:Organization
Organization Name:ATLANTIC SPACE COAST GI PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:TOBKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-632-0497
Mailing Address - Street 1:1009 HARVIN WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955
Mailing Address - Country:US
Mailing Address - Phone:321-632-0497
Mailing Address - Fax:321-631-7746
Practice Address - Street 1:1009 HARVIN WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-632-0497
Practice Address - Fax:321-631-7746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060192207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24931Medicare ID - Type Unspecified