COASTAL CARDIOLOGY A MEDICAL CORP

Provider Demographics

• NPI: 1962664888
• Name: COASTAL CARDIOLOGY A MEDICAL CORP
• Entity Type: Organization
• Organization Name: COASTAL CARDIOLOGY A MEDICAL CORP
• Authorized Official - Title/Position: COO/PRACTICE ADMINISTRATOR
• Authorized Official - First Name: MELISSA
• Authorized Official - Middle Name: L
• Authorized Official - Last Name: GOSS
• Authorized Official - Credentials: MHA
• Authorized Official - Phone: 805-782-8844
• Mailing Address - Street 1: 1941 JOHNSON AVE STE 101
• Mailing Address - City: SAN LUIS OBISPO
• Mailing Address - State: CA
• Mailing Address - Zip Code: 93401-4154
• Mailing Address - Country: US
• Mailing Address - Phone: 805-782-8844
• Mailing Address - Fax: 805-540-5827
• Practice Address - Street 1: 1941 JOHNSON AVE STE 102
• Practice Address - City: SAN LUIS OBISPO
• Practice Address - State: CA
• Practice Address - Zip Code: 93401-4154
• Practice Address - Country: US
• Practice Address - Phone: 805-782-8844
• Practice Address - Fax: 813-613-2633
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2008-07-01
• Last Update Date: 2022-07-09

Provider Licenses

State	License ID	Taxonomies
		207RC0000X, 207U00000X
CA	A105051	207RC0000X
CA	A99253	207RC0000X
CA	A54052	207RC0000X
CA	G56853	207RC0000X
CA	A116056	207RC0000X
CA	G44009	207RC0000X
CA	C128646	207RC0001X
CA	A114658	207RI0011X
CA	A63687	207RI0011X
CA	G54180	207RI0011X
CA	G29696	207RI0011X
CA	G69997	207RI0011X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207RC0000X	Allopathic & Osteopathic Physicians	Internal Medicine	Cardiovascular Disease	Group - Multi-Specialty
No	207RC0001X	Allopathic & Osteopathic Physicians	Internal Medicine	Clinical Cardiac Electrophysiology	Group - Multi-Specialty
No	207RI0011X	Allopathic & Osteopathic Physicians	Internal Medicine	Interventional Cardiology	Group - Multi-Specialty
No	207U00000X	Allopathic & Osteopathic Physicians	Nuclear Medicine		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
CA	GR000068680	Medicaid
CA	CP1074	Other	RR MEDICARE
CA	ZZZ28458Z	Other	BLUE SHIELD
CA	WG54180M	Medicare PIN
CA	WG69997O	Medicare PIN
CA	ZZZ28458Z	Other	BLUE SHIELD
CA	CP1074	Other	RR MEDICARE
CA	WA63687I	Medicare PIN
CA	WG29073M	Medicare PIN
CA	WA54052M	Medicare PIN
CA	WG56853M	Medicare PIN
CA	WG21420C	Medicare PIN
CA	WG44009K	Medicare PIN
CA	WG5853OJ	Medicare PIN