Provider Demographics
NPI:1700571726
Name:ATLANTIC UROLOGY CLINIC LLC
Entity Type:Organization
Organization Name:ATLANTIC UROLOGY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHADEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARZOUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-922-5961
Mailing Address - Street 1:823 82ND PKWY UNIT C
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4607
Mailing Address - Country:US
Mailing Address - Phone:843-839-6624
Mailing Address - Fax:843-839-6225
Practice Address - Street 1:823 82ND PKWY UNIT C
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-839-6624
Practice Address - Fax:843-839-6225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy