Provider Demographics
NPI:1508801036
Name:COASTAL FOOT AND ANKLE CLINIC PA.
Entity Type:Organization
Organization Name:COASTAL FOOT AND ANKLE CLINIC PA.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:850-653-3338
Mailing Address - Street 1:221 AVENUE E
Mailing Address - Street 2:
Mailing Address - City:APALACHICOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32320-1867
Mailing Address - Country:US
Mailing Address - Phone:850-653-3338
Mailing Address - Fax:850-653-3339
Practice Address - Street 1:221 AVENUE E
Practice Address - Street 2:
Practice Address - City:APALACHICOLA
Practice Address - State:FL
Practice Address - Zip Code:32320-1867
Practice Address - Country:US
Practice Address - Phone:850-653-3338
Practice Address - Fax:850-653-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 2869213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2744Medicare ID - Type Unspecified
FL4122830001Medicare NSC