Provider Demographics
NPI:1053441147
Name:COASTAL DIGESTIVE DISEASES PC
Entity Type:Organization
Organization Name:COASTAL DIGESTIVE DISEASES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:S
Authorized Official - Last Name:OUELLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-442-0290
Mailing Address - Street 1:234A BANK ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6054
Mailing Address - Country:US
Mailing Address - Phone:860-442-0290
Mailing Address - Fax:860-442-2136
Practice Address - Street 1:234 BANK ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-6070
Practice Address - Country:US
Practice Address - Phone:860-442-0290
Practice Address - Fax:860-442-2136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3032224000207QA0505X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty