Provider Demographics
NPI:1912576851
Name:COASTAL VASCULAR AND INTERVENTIONAL PLLC
Entity Type:Organization
Organization Name:COASTAL VASCULAR AND INTERVENTIONAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DANELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-479-1805
Mailing Address - Street 1:PO BOX 11982
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32524-1982
Mailing Address - Country:US
Mailing Address - Phone:850-479-1805
Mailing Address - Fax:850-479-1829
Practice Address - Street 1:4012 COMMONS DR W STE 110
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-8424
Practice Address - Country:US
Practice Address - Phone:850-479-1805
Practice Address - Fax:850-479-1829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty