MEDICARE: ATLANTIC UROLOGY CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1346645306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIC UROLOGY CLINIC LLC

Provider Business Mailing Address
First Line	:	2270 COLONIAL BLVD
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1412
Country	:	US
Telephone Number	:	239-931-7342
Fax Number	:	239-931-7385

Provider Business Practice Location Address
First Line	:	199 VILLAGE CENTER BLVD
Second Line	:	SUITE 100
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-3589
Country	:	US
Telephone Number	:	843-236-4330
Fax Number	:	843-236-5253

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KIM COMMINS
Credential	:
Telephone Number	:	239-931-7277

Provider Enumeration Date	:	11/03/2014
Last Update Date	:	07/29/2019

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