Provider Demographics
NPI:1922038173
Name:COASTAL RADIATION ONCOLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:COASTAL RADIATION ONCOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-648-5191
Mailing Address - Street 1:100 CASA ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1883
Mailing Address - Country:US
Mailing Address - Phone:805-541-1932
Mailing Address - Fax:831-684-7714
Practice Address - Street 1:1213 E OCEAN AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7043
Practice Address - Country:US
Practice Address - Phone:805-736-8628
Practice Address - Fax:805-736-8785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19778AMedicare PIN
W19778Medicare PIN
CAW19778BMedicare PIN