Provider Demographics
NPI:1861752784
Name:INTRACOASTAL MEDICAL PRIMARY HEALTH CARE, INC
Entity type:Organization
Organization Name:INTRACOASTAL MEDICAL PRIMARY HEALTH CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPST
Authorized Official - Prefix:
Authorized Official - First Name:HARISH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOWDARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-302-4902
Mailing Address - Street 1:935 INTRACOASTAL DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3623
Mailing Address - Country:US
Mailing Address - Phone:954-561-6252
Mailing Address - Fax:954-530-7516
Practice Address - Street 1:935 INTRACOASTAL DR
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3623
Practice Address - Country:US
Practice Address - Phone:954-561-6252
Practice Address - Fax:954-530-7516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty