Basic Information
| Provider Information | |||||||||
| NPI: | 1679562201 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL HOSPITALIST MEDICAL ASSOCIATES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 AVENIDA ENCINAS | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920084381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604396581 | ||||||||
| FaxNumber: | 7604396585 | ||||||||
| Practice Location | |||||||||
| Address1: | 4002 VISTA WAY | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920564506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604396581 | ||||||||
| FaxNumber: | 7607696585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 04/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | O'BRIEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7604396581 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GR0098700 | 05 | CA | MEDICAID |