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General NPI Number Information
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NPI Number | 1427203348
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Entity Type | Organization
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Legal Business Name | ATLANTIC ENT LLC
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Dates
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Enumeration Date | 11/19/2008
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Last Update Date | 11/19/2008
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Provider Practice Location Address
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Address Line | 333 W COCOA BEACH CSWY STE B
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City | COCOA BEACH
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State | FL
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Zip | 32931-3513
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Country | US
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Telephone | 321-799-9797
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Fax | 321-799-3393
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Provider Business Mailing Address
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Address Line | 333 W COCOA BEACH CSWY STE B
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City | COCOA BEACH
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State | FL
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Zip | 32931-3513
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Country | US
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Telephone | 321-799-9797
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Fax |
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Authorized Official
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Title or Position | SOLE MBR
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Name | DR. MICHAEL PAUL WIDICK
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Credential | M.D.
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Telephone | 321-799-9797
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YX0602X
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Taxonomy Name | Otolaryngic Allergy Physician
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License Number | ME0061454
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License Number State | FL
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