Basic Information
| Provider Information | |||||||||
| NPI: | 1942248174 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL COAST PHYSICAL MEDICINE AND REHABILITATION MEDICAL GROUP INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REHABILITATION MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1206 | ||||||||
| Address2: | |||||||||
| City: | GOLETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931161206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055698922 | ||||||||
| FaxNumber: | 8056875467 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 DE LA VINA ST | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931053819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056877444 | ||||||||
| FaxNumber: | 8056873707 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARRY | ||||||||
| AuthorizedOfficialFirstName: | ROSS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8055698922 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/09/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 225400000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 208100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1942248174 | 05 | CA | MEDICAID |