Provider Demographics
NPI:1396290409
Name:AQUARIUS PHYSICIANS GROUP
Entity type:Organization
Organization Name:AQUARIUS PHYSICIANS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHATANOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-790-4177
Mailing Address - Street 1:749 US HIGHWAY 1
Mailing Address - Street 2:SUITE 210
Mailing Address - City:NORTH PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-4400
Mailing Address - Country:US
Mailing Address - Phone:561-790-4177
Mailing Address - Fax:
Practice Address - Street 1:749 US HIGHWAY 1
Practice Address - Street 2:SUITE 210
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-4400
Practice Address - Country:US
Practice Address - Phone:561-790-4177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL16000150039OtherSTATE LICENSE NUMBER