1487682621 NPI number — COAST UROLOGY MEDICAL GROUP, INC

Table of content: (NPI 1487682621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487682621 NPI number — COAST UROLOGY MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COAST UROLOGY MEDICAL GROUP, 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:
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:
1487682621
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9850 GENESEE AVE
Provider Second Line Business Mailing Address:
STE 440
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-1224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-453-5944
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 SANTA FE DR
Provider Second Line Business Practice Location Address:
STE 305
Provider Business Practice Location Address City Name:
ENCINITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92024-5138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-453-5944
Provider Business Practice Location Address Fax Number:
858-552-2182
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUTLER
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-453-5944

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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