Provider Demographics
NPI:1790852994
Name:ATLANTIC SURGERY CENTER LLC
Entity Type:Organization
Organization Name:ATLANTIC SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-651-8211
Mailing Address - Street 1:3911 HIGHWAY 17 BYPASS
Mailing Address - Street 2:SUITE B
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-5014
Mailing Address - Country:US
Mailing Address - Phone:843-651-8211
Mailing Address - Fax:843-651-8882
Practice Address - Street 1:3911 HIGHWAY 17
Practice Address - Street 2:SUITE B
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-5014
Practice Address - Country:US
Practice Address - Phone:843-651-8211
Practice Address - Fax:843-651-8882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCASF-085261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCY14789Medicare UPIN