Provider Demographics
NPI:1366475766
Name:COASTAL IMAGING LLC
Entity Type:Organization
Organization Name:COASTAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUXIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-448-6094
Mailing Address - Street 1:565 LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4166
Mailing Address - Country:US
Mailing Address - Phone:860-448-6094
Mailing Address - Fax:860-448-6215
Practice Address - Street 1:565 LONG HILL RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4166
Practice Address - Country:US
Practice Address - Phone:860-448-6094
Practice Address - Fax:860-448-6215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0336672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004234845Medicaid
CTC02988Medicare PIN