1568542256 NPI number — COASTAL ENT MEDICAL GROUP INC

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 1568542256 NPI number — COASTAL ENT MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL ENT 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:
6
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:
1568542256
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9834 GENESEE AVE
Provider Second Line Business Mailing Address:
SUITE 416
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-1223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-457-1287
Provider Business Mailing Address Fax Number:
858-452-9160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9834 GENESEE AVE
Provider Second Line Business Practice Location Address:
SUITE 416
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-1223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-457-1287
Provider Business Practice Location Address Fax Number:
858-452-9160
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HALSEY
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-458-1287

Provider Taxonomy Codes

  • Taxonomy code: 207YX0905X , with the licence number:  G30707 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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