Provider Demographics
NPI:1134467533
Name:HOUSE CALLS OF COASTAL GEORGIA, PC
Entity Type:Organization
Organization Name:HOUSE CALLS OF COASTAL GEORGIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ISMAEL
Authorized Official - Middle Name:SALIM
Authorized Official - Last Name:OSTA
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:912-581-6913
Mailing Address - Street 1:811 SAND DOLLAR TRCE
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-3761
Mailing Address - Country:US
Mailing Address - Phone:912-580-6913
Mailing Address - Fax:912-265-1212
Practice Address - Street 1:811 SAND DOLLAR TRCE
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-3761
Practice Address - Country:US
Practice Address - Phone:912-580-6913
Practice Address - Fax:912-265-2859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-21
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
15631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA021787368CMedicaid
GA00069297A3Medicaid
GAD99645Medicare UPIN
GAP83613Medicare UPIN