Provider Demographics
NPI:1891778171
Name:COASTAL PAIN CARE PA
Entity Type:Organization
Organization Name:COASTAL PAIN CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHARLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-892-4600
Mailing Address - Street 1:755 N 11TH ST
Mailing Address - Street 2:SUITE P2280
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1501
Mailing Address - Country:US
Mailing Address - Phone:409-892-4600
Mailing Address - Fax:409-892-4605
Practice Address - Street 1:755 N 11TH ST
Practice Address - Street 2:SUITE P2280
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1501
Practice Address - Country:US
Practice Address - Phone:409-892-4600
Practice Address - Fax:409-892-4605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175364201Medicaid
TX0027MWOtherBLUE CROSS
TX0027MWOtherBLUE CROSS