1174588255 NPI number — COASTAL CARDIOLOGY P A

Table of content: (NPI 1174588255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174588255 NPI number — COASTAL CARDIOLOGY P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL CARDIOLOGY P A
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:
1174588255
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 24853
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33102-4853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-274-8866
Provider Business Mailing Address Fax Number:
239-274-8867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16261 BASS RD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33908-3671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-274-8866
Provider Business Practice Location Address Fax Number:
239-274-8867
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CONRAD
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
STAFF PHYSICIAN
Authorized Official Telephone Number:
239-274-8866

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 273264500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 74608 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DD8590 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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