Provider Demographics
NPI:1659418077
Name:COASTAL PEDIATRICS, LLC
Entity Type:Organization
Organization Name:COASTAL PEDIATRICS, LLC
Other - Org Name:COASTAL PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DUDLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-353-7744
Mailing Address - Street 1:1000 TOWNE CENTER BLVD STE 1000B
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4129
Mailing Address - Country:US
Mailing Address - Phone:912-353-7744
Mailing Address - Fax:912-348-3589
Practice Address - Street 1:1000 TOWNE CENTER BLVD STE 1000B
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322
Practice Address - Country:US
Practice Address - Phone:912-353-7744
Practice Address - Fax:912-348-3589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051088208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID NUMBER