Provider Demographics
NPI:1639239387
Name:COASTAL CARDIOLOGY, PC
Entity Type:Organization
Organization Name:COASTAL CARDIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHIMENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-202-3335
Mailing Address - Street 1:4211 HOSPITAL ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-5310
Mailing Address - Country:US
Mailing Address - Phone:228-202-3335
Mailing Address - Fax:228-202-3337
Practice Address - Street 1:4211 HOSPITAL ST
Practice Address - Street 2:SUITE 107
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5310
Practice Address - Country:US
Practice Address - Phone:228-202-3335
Practice Address - Fax:228-202-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18035207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00571214Medicaid
MS422390786COtherBCBS
MS00571214Medicaid
MSC03224Medicare PIN