Healthcare Provider Details

I. General information

NPI: 1962831883
Provider Name (Legal Business Name): ATLANTIC CARDIOVASCULAR & THORACIC SURGEONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 W GRANADA BLVD FL 2
ORMOND BEACH FL
32174-5915
US

IV. Provider business mailing address

1240 W GRANADA BLVD FL 2
ORMOND BEACH FL
32174-5915
US

V. Phone/Fax

Practice location:
  • Phone: 862-366-8543
  • Fax: 862-632-9963
Mailing address:
  • Phone: 386-236-6854
  • Fax: 386-263-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME36700
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME58979
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME58979
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME36700
License Number StateFL

VIII. Authorized Official

Name: WILLIAM HAMPTON JOHNSON III
Title or Position: OPERATING MANAGER
Credential: M.D.
Phone: 386-672-9503