Basic Information
| Provider Information | |||||||||
| NPI: | 1518160092 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL PATHOLOGY, INC. | ||||||||
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| OtherOrganizationName: | COASTAL PATHOLOGY, PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 658 GRASSMERE PARK STE 104 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372113683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159163200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3418 MIDCOURT RD. | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144208200 | ||||||||
| FaxNumber: | 2144208205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2007 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROBLES | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | WARREN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2144208200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZD0900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZH0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.