Provider Demographics
NPI:1497763981
Name:COASTAL STATES MANAGEMENT
Entity Type:Organization
Organization Name:COASTAL STATES MANAGEMENT
Other - Org Name:SOUTHEASTERN PAIN MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-492-7246
Mailing Address - Street 1:1026 GOODYEAR AVE
Mailing Address - Street 2:BLDG 400, STE 302
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-1102
Mailing Address - Country:US
Mailing Address - Phone:256-492-7246
Mailing Address - Fax:256-492-1168
Practice Address - Street 1:1026 GOODYEAR AVE
Practice Address - Street 2:BLDG 400, STE 302
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-1102
Practice Address - Country:US
Practice Address - Phone:256-492-7246
Practice Address - Fax:256-492-1168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD0536174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALG62111OtherHEALTHSPRINGS OF ALABAMA
ALG62111OtherHUMANA GOLD
ALG62111Medicare UPIN