Basic Information
| Provider Information | |||||||||
| NPI: | 1336664424 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL RADIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 686 | ||||||||
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| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544020686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8334170599 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2 MACARTHUR PL STE 300 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927075924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134613573 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2017 | ||||||||
| LastUpdateDate: | 08/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | CASSIN | ||||||||
| AuthorizedOfficialFirstName: | NAOMI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3127248477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.