Provider Demographics
NPI:1760580104
Name:COAST ORTHOPEDIC CENTER PA
Entity Type:Organization
Organization Name:COAST ORTHOPEDIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-269-4300
Mailing Address - Street 1:1781 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3221
Mailing Address - Country:US
Mailing Address - Phone:321-269-4300
Mailing Address - Fax:321-269-7755
Practice Address - Street 1:1781 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3221
Practice Address - Country:US
Practice Address - Phone:321-269-4300
Practice Address - Fax:321-269-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51090174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046402300Medicaid
FLD50970Medicare UPIN
FL046402300Medicaid