Basic Information
| Provider Information | |||||||||
| NPI: | 1588637169 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL ANESTHESIA, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 851417 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366851417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513423000 | ||||||||
| FaxNumber: | 2513423043 | ||||||||
| Practice Location | |||||||||
| Address1: | 3719 DAUPHIN ST | ||||||||
| Address2: | SPRINGHILL MEDICAL CENTER ANESTHESIA DEPT | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513423000 | ||||||||
| FaxNumber: | 2513423043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 03/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOUDREAUX | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2513423000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | CN0216 | 01 | AL | MEDICARE TRAVELERS | OTHER |