Provider Demographics
NPI:1467780494
Name:COASTAL SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:COASTAL SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-334-1733
Mailing Address - Street 1:1594 ROUTE 9
Mailing Address - Street 2:UNIT 6
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-3280
Mailing Address - Country:US
Mailing Address - Phone:732-349-8888
Mailing Address - Fax:732-349-8880
Practice Address - Street 1:1594 ROUTE 9
Practice Address - Street 2:UNIT 6
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-3280
Practice Address - Country:US
Practice Address - Phone:732-349-8888
Practice Address - Fax:732-349-8880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06570700207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty