Provider Demographics
NPI:1417985094
Name:COASTAL SPINE PC
Entity Type:Organization
Organization Name:COASTAL SPINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGUERITE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZOLTEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-222-4444
Mailing Address - Street 1:4000 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-1110
Mailing Address - Country:US
Mailing Address - Phone:856-222-4444
Mailing Address - Fax:
Practice Address - Street 1:4000 CHURCH RD
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-1110
Practice Address - Country:US
Practice Address - Phone:856-222-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ069103Medicare PIN
NJ5511390001Medicare NSC