Provider Demographics
NPI:1194816892
Name:COAST UROLOGICAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:COAST UROLOGICAL MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:HIGHTOWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-430-0581
Mailing Address - Street 1:3771 KATELLA AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3118
Mailing Address - Country:US
Mailing Address - Phone:562-430-0581
Mailing Address - Fax:562-598-2110
Practice Address - Street 1:3771 KATELLA AVE STE 210
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720
Practice Address - Country:US
Practice Address - Phone:562-430-0581
Practice Address - Fax:562-598-2110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ75909ZMedicaid
CAZZZ75909ZMedicaid