Provider Demographics
NPI:1144281247
Name:ATLANTIC MEDICAL GROUP
Entity type:Organization
Organization Name:ATLANTIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-726-6331
Mailing Address - Street 1:1541 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3540
Mailing Address - Country:US
Mailing Address - Phone:321-726-6331
Mailing Address - Fax:321-726-6371
Practice Address - Street 1:1541 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3540
Practice Address - Country:US
Practice Address - Phone:321-726-6331
Practice Address - Fax:321-726-6371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88828207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
159351XXOtherPREFERRED CARE PROVIDER #
37972OtherBCBS PROVIDER ID
1809978OtherFIRST HEALTH PROVIDER NO.
9303692OtherCIGNA PROVIDER NO.
DD4702OtherRAILROAD MCARE GROUP #
P00022983OtherRAILROAD MCARE PROVIDER #
246370OtherWELLCARE MCAID PROVIDER #
5585831OtherCCN NETWORK PROVIDER NO.
7274610OtherAETNA PROVIDER NO.
10024OtherFLORIDIANCARE PROVIDER #
9362860OtherPHCS PROVIDER #
7274610OtherAETNA PROVIDER NO.
K7619Medicare ID - Type UnspecifiedGROUP PROVIDER NO.
159351XXOtherPREFERRED CARE PROVIDER #