COASTAL CARDIOLOGY A MEDICAL CORP

Provider Demographics

• NPI: 1720183569
• Name: COASTAL CARDIOLOGY A MEDICAL CORP
• Entity Type: Organization
• Organization Name: COASTAL CARDIOLOGY A MEDICAL CORP
• Authorized Official - Title/Position: PRACTICE ADMINISTRATOR, COO
• 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
• Mailing Address - Street 2: SUITE 101
• Mailing Address - City: SAN LUIS OBISPO
• Mailing Address - State: CA
• Mailing Address - Zip Code: 93401
• Mailing Address - Country: US
• Mailing Address - Phone: 805-782-8844
• Mailing Address - Fax: 805-782-8859
• Practice Address - Street 1: 1941 JOHNSON AVE STE 101
• Practice Address - City: SAN LUIS OBISPO
• Practice Address - State: CA
• Practice Address - Zip Code: 93401-4154
• Practice Address - Country: US
• Practice Address - Phone: 805-782-8844
• Practice Address - Fax: 813-613-2634
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-09-14
• Last Update Date: 2022-07-09

Provider Licenses

State	License ID	Taxonomies
CA	A105051	207RC0000X
CA	A54052	207RC0000X
CA	G56853	207RC0000X
CA	A116056	207RC0000X
CA	G44009	207RC0000X
CA	G58530	207RC0000X
		207RC0000X
CA	C128646	207RC0001X
CA	A63687	207RI0011X
CA	A99253	207RI0011X
CA	G54180	207RI0011X
CA	G29696	207RI0011X
CA	A114658	207RI0011X
CA	G69997	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	363AM0700X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant	Medical	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
	CP1074	Other	MEDICARE RR
CA	ZZZ24859Z	Other	BLUE SHIELD
CA	GR0068680	Medicaid
CA	HW8858D	Medicare PIN
CA	ZZZ24859Z	Other	BLUE SHIELD
CA	GR0068680	Medicaid
CA	W8858B	Medicare PIN
CA	HW8858A	Medicare PIN
CA	HW8858	Medicare PIN
CA	W8858A	Medicare PIN
	HW8858B	Medicare PIN
CA	W8858	Medicare PIN