Provider Demographics
NPI:1003361767
Name:COASTLINE MEDICAL SERVICES PLLC
Entity Type:Organization
Organization Name:COASTLINE MEDICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVERNARIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-396-1110
Mailing Address - Street 1:208 MARY ESTHER BLVD
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1687
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 MARY ESTHER BLVD
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1687
Practice Address - Country:US
Practice Address - Phone:908-265-8949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-23
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QS0010X
FLME116308261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty