Provider Demographics
NPI:1073795894
Name:COASTAL UROLOGY ASSOCIATES PA
Entity Type:Organization
Organization Name:COASTAL UROLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-840-4300
Mailing Address - Street 1:900 ROUTE 70 EAST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5940
Mailing Address - Country:US
Mailing Address - Phone:732-840-4300
Mailing Address - Fax:732-840-4515
Practice Address - Street 1:900 ROUTE 70 EAST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5940
Practice Address - Country:US
Practice Address - Phone:732-840-4300
Practice Address - Fax:732-840-4515
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL UROLOGY ASSOCIATES PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA32274002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ527288Medicare PIN