1043312515 NPI number — COASTAL GASTROENTEROLOGY ASSOCIATES, PA

Table of content: (NPI 1043312515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043312515 NPI number — COASTAL GASTROENTEROLOGY ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL GASTROENTEROLOGY ASSOCIATES, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043312515
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1015 MEDICAL CENTER BLVD
Provider Second Line Business Mailing Address:
SUITE 1300
Provider Business Mailing Address City Name:
WEBSTER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77598-4052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-557-2527
Provider Business Mailing Address Fax Number:
281-557-7203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 MEDICAL CENTER BLVD
Provider Second Line Business Practice Location Address:
SUITE 1300
Provider Business Practice Location Address City Name:
WEBSTER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77598-4052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-557-2527
Provider Business Practice Location Address Fax Number:
281-557-7203
Provider Enumeration Date:
09/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SUBRAMANYAM
Authorized Official First Name:
KALYANAM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
281-557-2527

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2226780 . This is a "BCBS - TX - BLUE LINK ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5283 . This is a "RR MCR GROUP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4102895 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00440059 . This is a "RR MCR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1164493870 . This is a "NPI - INDIVIDUAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: B26780 . This is a "MCR UPIN - INDIVIDUAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 114758902 . This is a "THMP - DR. SUBRAMANYAM" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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