Provider Demographics
NPI:1447293790
Name:ATLANTIC UROLOGY CLINICS LLC
Entity type:Organization
Organization Name:ATLANTIC UROLOGY CLINICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:US PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHADEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARZOUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-931-7254
Mailing Address - Street 1:1419 SE 8TH TER STE 200
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-3213
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:
Practice Address - Street 1:3600 SEA MOUNTAIN HWY STE B
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-8161
Practice Address - Country:US
Practice Address - Phone:843-399-9696
Practice Address - Fax:843-399-9596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4522Medicaid
SCGP4522Medicaid
NC232012Medicare PIN