1609616291 NPI number — COASTAL TIDES SURGICAL CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609616291 NPI number — COASTAL TIDES SURGICAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL TIDES SURGICAL CENTER, LLC
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:
1609616291
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1002 N ARNOLD ROAD
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
PANAMA CITY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 N ARNOLD ROAD
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
PANAMA CITY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-509-7567
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2024

Additional Information

Authorized Official

Authorized Official Last Name:
STANNARD
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
850-509-7567

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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