Basic Information
| Provider Information | |||||||||
| NPI: | 1568609444 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL ORTHOPEDICS & SPORTS MEDICINE OF SOUTHWEST FL, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6015 POINTE WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342095532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417921404 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8340 LAKEWOOD RANCH BLVD | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342025180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417921404 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2009 | ||||||||
| LastUpdateDate: | 10/31/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/27/2018 | ||||||||
| NPIReactivationDate: | 10/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | LEMAY | ||||||||
| AuthorizedOfficialFirstName: | PAIGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9417921404 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 264533500 | 05 | FL | MEDICAID |