Basic Information
| Provider Information | |||||||||
| NPI: | 1902860836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH COAST ANESTHESIA ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5319 SW WESTGATE DR | ||||||||
| Address2: | 241 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972212432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032977223 | ||||||||
| FaxNumber: | 5032977603 | ||||||||
| Practice Location | |||||||||
| Address1: | 2699 N 17TH ST | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412697358 | ||||||||
| FaxNumber: | 5412690677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | BEECHLY | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5412697358 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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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 | 029025 | 05 | OR | MEDICAID |