Provider Demographics
NPI:1578525739
Name:AMITABH GUPTA MD PA
Entity Type:Organization
Organization Name:AMITABH GUPTA MD PA
Other - Org Name:COASTAL ORTHOPEDIC MEDICINE, PAIN MANAGEMENT & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMITABH
Authorized Official - Middle Name:P
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-526-8000
Mailing Address - Street 1:5800 49TH ST N
Mailing Address - Street 2:SUITE S-205
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2146
Mailing Address - Country:US
Mailing Address - Phone:727-526-8000
Mailing Address - Fax:727-521-2600
Practice Address - Street 1:5800 49TH ST N
Practice Address - Street 2:SUITE S-205
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2146
Practice Address - Country:US
Practice Address - Phone:727-526-8000
Practice Address - Fax:727-521-2600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2008-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85225261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17034OtherBL CRS/BL SHLD PROVIDER #
FL79665328OtherAETNA PROVIDER NO.
FL299916OtherAVMED PROVIDER NO.
FL2799066OtherGHI PROVIDER NO.
FL304583OtherWELLCARE PROVIDER NO.
FLAS34873800001OtherCIGNA PROVIDER NO.
FL2744716Medicaid
FL79665328OtherAETNA PROVIDER NO.
FLK8944Medicare PIN
FL6148200001Medicare NSC
FL2799066OtherGHI PROVIDER NO.