Provider Demographics
NPI:1942248174
Name:CENTRAL COAST PHYSICAL MEDICINE AND REHABILITATION MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:CENTRAL COAST PHYSICAL MEDICINE AND REHABILITATION MEDICAL GROUP INC.
Other - Org Name:REHABILITATION MEDICAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-569-8922
Mailing Address - Street 1:PO BOX 1206
Mailing Address - Street 2:
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93116-1206
Mailing Address - Country:US
Mailing Address - Phone:805-569-8922
Mailing Address - Fax:805-687-5467
Practice Address - Street 1:2415 DE LA VINA ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-3819
Practice Address - Country:US
Practice Address - Phone:805-687-7444
Practice Address - Fax:805-687-3707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 208100000X
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1942248174Medicaid
CAW9293Medicare PIN
CAW9293DMedicare PIN
CAW9293EMedicare PIN