1457358434 NPI number — COASTAL NEUROLOGY, INC.

Table of content: (NPI 1457358434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457358434 NPI number — COASTAL NEUROLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL NEUROLOGY, INC.
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:
COASTAL PAIN MGMT, NEUROLOGY & REHABILITATION
Provider Other Organization Name Type Code:
3
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:
1457358434
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
725 W GRANADA BLVD
Provider Second Line Business Mailing Address:
SUITE 22
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-788-2300
Provider Business Mailing Address Fax Number:
386-944-6622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 W GRANADA BLVD
Provider Second Line Business Practice Location Address:
SUITE 22
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-788-2300
Provider Business Practice Location Address Fax Number:
386-944-6622
Provider Enumeration Date:
07/05/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
NEIL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
386-788-2300

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: OS5774 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0014X , with the licence number: ME84820 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA1823 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: E60482 . This is a "INDIVIDUAL-BENEZETTE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 117644600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".