Healthcare Provider Details

I. General information

NPI: 1053532572
Provider Name (Legal Business Name): ATLANTIC UROLOGICAL ASSOCIATES P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 OLD MOULTRIE RD SUITE 5
ST AUGUSTINE FL
32086-4197
US

IV. Provider business mailing address

545 HEALTH BLVD
DAYTONA BEACH FL
32114-1493
US

V. Phone/Fax

Practice location:
  • Phone: 904-794-7870
  • Fax:
Mailing address:
  • Phone: 386-239-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: JERRI CREGGAR
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 386-239-8500