Basic Information
| Provider Information | |||||||||
| NPI: | 1518199223 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ATLANTIC IMMEDICARE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10026 OLD OCEAN CITY BLVD | ||||||||
| Address2: | BUILDING ONE | ||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106419450 | ||||||||
| FaxNumber: | 4106419515 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 PHILADELPHIA AVE | ||||||||
| Address2: | |||||||||
| City: | OCEAN CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218423735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106419450 | ||||||||
| FaxNumber: | 4106419515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2009 | ||||||||
| LastUpdateDate: | 08/13/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRANNON | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRES OF PROFESSIONAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4106419341 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ATLANTIC GENERAL HOSPITAL CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CHE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.