Basic Information
Provider Information | |||||||||
NPI: | 1588111082 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COASTAL ER V, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PHYSICIANS PREMIER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6040 | ||||||||
Address2: |   | ||||||||
City: | CORPUS CHRISTI | ||||||||
State: | TX | ||||||||
PostalCode: | 784666040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3618842904 | ||||||||
FaxNumber: | 3618841912 | ||||||||
Practice Location | |||||||||
Address1: | 11158 LEOPARD ST STE 103 | ||||||||
Address2: |   | ||||||||
City: | CORPUS CHRISTI | ||||||||
State: | TX | ||||||||
PostalCode: | 784102612 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3619910811 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2016 | ||||||||
LastUpdateDate: | 11/01/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KENYON | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | LLC BOARD MEMBER | ||||||||
AuthorizedOfficialTelephone: | 3619910811 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | 160281 | TX | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care |
ID Information
ID | Type | State | Issuer | Description | 160281 | 01 | TX | TDSHS FEC LICENSE | OTHER |