Provider Demographics
NPI:1417304643
Name:COASTAL PEDIATRIC GROUP
Entity Type:Organization
Organization Name:COASTAL PEDIATRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SPRENKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-659-6556
Mailing Address - Street 1:36468 EMERALD COAST PKWY UNIT 2101
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541
Mailing Address - Country:US
Mailing Address - Phone:850-659-6556
Mailing Address - Fax:850-249-1308
Practice Address - Street 1:36468 EMERALD COAST PKWY UNIT 2101
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541
Practice Address - Country:US
Practice Address - Phone:850-659-6556
Practice Address - Fax:850-249-1308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87333208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty