Provider Demographics
NPI:1588845978
Name:COASTAL PHYSICIANS MEDICAL GROUP
Entity Type:Organization
Organization Name:COASTAL PHYSICIANS MEDICAL GROUP
Other - Org Name:COASTAL PHYSICIANS MEDICAL GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:MAGDALENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-832-4225
Mailing Address - Street 1:824 E CARSON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2262
Mailing Address - Country:US
Mailing Address - Phone:310-233-3202
Mailing Address - Fax:310-233-3208
Practice Address - Street 1:824 E CARSON ST STE 101
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2262
Practice Address - Country:US
Practice Address - Phone:310-233-3202
Practice Address - Fax:310-233-3208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13983BMedicare PIN