Provider Demographics
NPI:1275052755
Name:COASTAL FOOT & ANKLE INC
Entity Type:Organization
Organization Name:COASTAL FOOT & ANKLE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SABOURIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:508-258-1717
Mailing Address - Street 1:850 AQUIDNECK AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-7280
Mailing Address - Country:US
Mailing Address - Phone:401-849-2157
Mailing Address - Fax:401-848-8441
Practice Address - Street 1:850 AQUIDNECK AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-7280
Practice Address - Country:US
Practice Address - Phone:401-849-2157
Practice Address - Fax:401-848-8441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDPM00316213ES0103X
MA2210261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIFH00185Medicaid