Provider Demographics
NPI:1508303280
Name:COASTAL NEUROLOGIC INSTITUTE
Entity Type:Organization
Organization Name:COASTAL NEUROLOGIC INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MCCLENDON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:205-382-0908
Mailing Address - Street 1:30762 STATE HIGHWAY 181
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORT
Mailing Address - State:AL
Mailing Address - Zip Code:36527-5672
Mailing Address - Country:US
Mailing Address - Phone:205-382-0908
Mailing Address - Fax:
Practice Address - Street 1:30762 STATE HIGHWAY 181
Practice Address - Street 2:
Practice Address - City:SPANISH FORT
Practice Address - State:AL
Practice Address - Zip Code:36527-5672
Practice Address - Country:US
Practice Address - Phone:205-382-0908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty