Basic Information
| Provider Information | |||||||||
| NPI: | 1013969260 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL ORTHOPAEDICS AND SPORTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5145 DEER PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278481417 | ||||||||
| FaxNumber: | 7278477526 | ||||||||
| Practice Location | |||||||||
| Address1: | 5145 DEER PARK DR | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346537013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278481417 | ||||||||
| FaxNumber: | 7278477526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 04/21/2011 | ||||||||
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| AuthorizedOfficialLastName: | CANDELORA | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7278481417 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | CD6290 | 01 | RAILROAD MEDICARE | OTHER |