Provider Demographics
NPI:1780021725
Name:COASTAL ORTHOPAEDICS, PC
Entity Type:Organization
Organization Name:COASTAL ORTHOPAEDICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:LYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-845-2200
Mailing Address - Street 1:761 MAIN AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-1080
Mailing Address - Country:US
Mailing Address - Phone:203-845-2200
Mailing Address - Fax:203-847-1940
Practice Address - Street 1:30 EAST AVE
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-5516
Practice Address - Country:US
Practice Address - Phone:203-845-2200
Practice Address - Fax:203-847-1940
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL ORTHOPAEDICS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-31
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207X00000X, 207XP3100X, 207XS0106X, 207XS0117X, 207XX0004X, 207XX0005X, 207XX0801X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic SurgeryGroup - Single Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C02816Medicare PIN
0378520008Medicare NSC