Provider Demographics
NPI:1184187254
Name:COASTAL MEDICAL AND ANESTHESIA, INC
Entity Type:Organization
Organization Name:COASTAL MEDICAL AND ANESTHESIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:731-926-0431
Mailing Address - Street 1:183 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-6036
Mailing Address - Country:US
Mailing Address - Phone:731-926-0431
Mailing Address - Fax:
Practice Address - Street 1:935 WAYNE RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-1904
Practice Address - Country:US
Practice Address - Phone:731-926-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-07
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty