Basic Information
| Provider Information | |||||||||
| NPI: | 1992955637 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORAL REEF GASTROENTEROLGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7765 144TH STREET | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | SEBASTIAN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725890580 | ||||||||
| FaxNumber: | 7725890760 | ||||||||
| Practice Location | |||||||||
| Address1: | 7765 144TH STREET | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | SEBASTIAN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7725890580 | ||||||||
| FaxNumber: | 7725890760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 09/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | RUIZ | ||||||||
| AuthorizedOfficialFirstName: | MARGI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7725890580 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME95828 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.