Basic Information
| Provider Information | |||||||||
| NPI: | 1528065679 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL PATHOLOGY MEDICAL ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2425 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074458121 | ||||||||
| FaxNumber: | 7072693782 | ||||||||
| Practice Location | |||||||||
| Address1: | 2425 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074414420 | ||||||||
| FaxNumber: | 7072693889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | HINO | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7074414420 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 4779028 | 05 | CA | MEDICAID |