COASTAL CARDIOLOGY A MEDICAL CORP

Provider Demographics

• NPI: 1578725495
• Name: COASTAL CARDIOLOGY A MEDICAL CORP
• Entity Type: Organization
• Organization Name: COASTAL CARDIOLOGY A MEDICAL CORP
• Authorized Official - Title/Position: COO/PRACTICE ADMINISTRATOR
• Authorized Official - First Name: MELISSA
• Authorized Official - Last Name: GOSS
• Authorized Official - Credentials: MHA
• Authorized Official - Phone: 805-782-8844
• Mailing Address - Street 1: 1941 JOHNSON AVE STE 101
• Mailing Address - City: SAN LUIS OBISPO
• Mailing Address - State: CA
• Mailing Address - Zip Code: 93401-4154
• Mailing Address - Country: US
• Mailing Address - Phone: 805-782-8844
• Mailing Address - Fax: 805-782-8859
• Practice Address - Street 1: 310 SOUTH HALCYON ROAD STE 105
• Practice Address - City: ARROYO GRANDE
• Practice Address - State: CA
• Practice Address - Zip Code: 93420-3872
• Practice Address - Country: US
• Practice Address - Phone: 805-782-8844
• Practice Address - Fax: 813-613-2632
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2008-07-01
• Last Update Date: 2022-07-09

Provider Licenses

State	License ID	Taxonomies
CA		207RC0000X, 207UN0901X
CA	A105051	207RC0000X
CA	A54052	207RC0000X
CA	G56853	207RC0000X
CA	A116056	207RC0000X
CA	C128646	207RC0001X
CA	A114658	207RI0011X
CA	PA23186	363AM0700X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207RC0000X	Allopathic & Osteopathic Physicians	Internal Medicine	Cardiovascular Disease	Group - Multi-Specialty
No	207RC0001X	Allopathic & Osteopathic Physicians	Internal Medicine	Clinical Cardiac Electrophysiology	Group - Multi-Specialty
No	207RI0011X	Allopathic & Osteopathic Physicians	Internal Medicine	Interventional Cardiology	Group - Multi-Specialty
No	207UN0901X	Allopathic & Osteopathic Physicians	Nuclear Medicine	Nuclear Cardiology	Group - Multi-Specialty
No	363AM0700X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant	Medical	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
CA	GR0068680	Medicaid
CA	ZZZ24859Z	Other	BLUE SHIELD
CA	WG56853E	Medicare PIN
CA	ZZZ24859Z	Other	BLUE SHIELD
CA	WG29073D	Medicare PIN
CA	WG54180D	Medicare PIN
CA	WA54052E	Medicare PIN
CA	WA72324B	Medicare PIN
CA	WG21420D	Medicare PIN
CA	CP1074	Medicare PIN
CA	WG23388C	Medicare PIN
CA	WG44009C	Medicare PIN
CA	WG69997L	Medicare PIN
CA	WA63687F	Medicare PIN
CA	WG29696D	Medicare PIN
CA	W8858A	Medicare PIN
CA	GR0068680	Medicaid