Provider Demographics
NPI:1174588255
Name:COASTAL CARDIOLOGY P A
Entity type:Organization
Organization Name:COASTAL CARDIOLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-274-8866
Mailing Address - Street 1:PO BOX 24853
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33102-4853
Mailing Address - Country:US
Mailing Address - Phone:239-274-8866
Mailing Address - Fax:239-274-8867
Practice Address - Street 1:16261 BASS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3671
Practice Address - Country:US
Practice Address - Phone:239-274-8866
Practice Address - Fax:239-274-8867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273264500Medicaid
FL74608OtherBCBS
FLDD8590OtherRR MEDICARE
FL=========OtherTAX ID
FL273264500Medicaid