Provider Demographics
NPI:1821194754
Name:COASTAL SURGICAL SPECIALISTS, INC.
Entity Type:Organization
Organization Name:COASTAL SURGICAL SPECIALISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-739-3110
Mailing Address - Street 1:921 OAK PARK BLVD
Mailing Address - Street 2:101
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3264
Mailing Address - Country:US
Mailing Address - Phone:805-473-9850
Mailing Address - Fax:805-473-9851
Practice Address - Street 1:921 OAK PARK BLVD
Practice Address - Street 2:101
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3264
Practice Address - Country:US
Practice Address - Phone:805-473-9850
Practice Address - Fax:805-473-9851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA050000593261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS051690Medicare PIN