1972590552 NPI number — COASTAL MEDICAL INC

Table of content: (NPI 1972590552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972590552 NPI number — COASTAL MEDICAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL MEDICAL 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:
1972590552
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 DAVOL SQ
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02903-4754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-421-4000
Provider Business Mailing Address Fax Number:
401-272-1456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
272 W EXCHANGE ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02903-1061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-421-5434
Provider Business Practice Location Address Fax Number:
401-421-4633
Provider Enumeration Date:
09/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MOSS
Authorized Official First Name:
MERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
401-421-4000

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  00412 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1972590 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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