Provider Demographics
NPI:1962831883
Name:ATLANTIC CARDIOVASCULAR & THORACIC SURGEONS, LLC
Entity Type:Organization
Organization Name:ATLANTIC CARDIOVASCULAR & THORACIC SURGEONS, LLC
Other - Org Name:COASTAL CARDIOVASCULAR & THORACIC ASSOCIATES, P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HAMPTON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:386-672-9503
Mailing Address - Street 1:588 STERTHAUS DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5128
Mailing Address - Country:US
Mailing Address - Phone:386-672-9503
Mailing Address - Fax:386-672-0386
Practice Address - Street 1:588 STERTHAUS DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5128
Practice Address - Country:US
Practice Address - Phone:386-672-9503
Practice Address - Fax:386-672-0386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-01
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME367002086S0129X, 208G00000X
FLME589792086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD86198Medicare UPIN
FLHT021AMedicare PIN
HT021AMedicare PIN
FL64546YMedicare PIN