Provider Demographics
NPI:1164578928
Name:COASTAL NEUROSCIENCES PC
Entity Type:Organization
Organization Name:COASTAL NEUROSCIENCES PC
Other - Org Name:COASTAL PHYSICIANS & SURGEONS PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:S
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-653-9110
Mailing Address - Street 1:110 HARBOR LANE
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-2470
Mailing Address - Country:US
Mailing Address - Phone:609-653-9110
Mailing Address - Fax:609-653-4105
Practice Address - Street 1:110 HARBOR LANE
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2470
Practice Address - Country:US
Practice Address - Phone:609-653-9110
Practice Address - Fax:609-653-4105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7771908Medicaid
NJ7771908Medicaid