Provider Demographics
NPI:1538231956
Name:COASTAL MEDICAL CENTER LLC
Entity type:Organization
Organization Name:COASTAL MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-309-7006
Mailing Address - Street 1:1 S SCHOOL AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-6014
Mailing Address - Country:US
Mailing Address - Phone:941-308-8500
Mailing Address - Fax:941-308-8501
Practice Address - Street 1:1 S SCHOOL AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-6014
Practice Address - Country:US
Practice Address - Phone:941-308-8500
Practice Address - Fax:941-308-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1114261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF1343Medicare PIN
FLF1343Medicare ID - Type Unspecified