Provider Demographics
NPI:1609882216
Name:COASTAL CARDIOLOGY LLC
Entity Type:Organization
Organization Name:COASTAL CARDIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BODAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-789-5600
Mailing Address - Street 1:412 ALDER ST
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-9014
Mailing Address - Country:US
Mailing Address - Phone:541-412-7799
Mailing Address - Fax:
Practice Address - Street 1:412 ALDER ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9014
Practice Address - Country:US
Practice Address - Phone:541-412-7799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2498207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty