1194949248 NPI number — COASTAL MEDICAL SPECIALISTS IN LUNG & CRITICAL CARE, PC

Table of content: (NPI 1194949248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194949248 NPI number — COASTAL MEDICAL SPECIALISTS IN LUNG & CRITICAL CARE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL MEDICAL SPECIALISTS IN LUNG & CRITICAL CARE, PC
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:
1194949248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
411 STEPHENSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405-5968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-354-7679
Provider Business Mailing Address Fax Number:
912-354-4018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 STEPHENSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31405-5968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-354-7679
Provider Business Practice Location Address Fax Number:
912-354-4018
Provider Enumeration Date:
04/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OGUNTUMIBI
Authorized Official First Name:
ADEWUMI
Authorized Official Middle Name:
O
Authorized Official Title or Position:
CEO/MD
Authorized Official Telephone Number:
912-354-7679

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  049393 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00900797H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00900798C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 85003028G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000900798I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00900798G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00900798H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 930105831 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 00900798D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00900798E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00900798F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000900798M , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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