Basic Information
| Provider Information | |||||||||
| NPI: | 1235155789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL ORTHOPAEDIC INSTITUTE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 HANOVER ST | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027205246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086469525 | ||||||||
| FaxNumber: | 5086797177 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 HANOVER ST | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027205246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086469525 | ||||||||
| FaxNumber: | 5086797177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 11/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | MABIE | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5086469525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9779053 | 05 | MA | MEDICAID |