Provider Demographics
NPI:1972590552
Name:COASTAL MEDICAL INC
Entity Type:Organization
Organization Name:COASTAL MEDICAL INC
Other - Org Name:COASTAL MEDICAL LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-421-4000
Mailing Address - Street 1:10 DAVOL SQ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4754
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:401-272-1456
Practice Address - Street 1:272 W EXCHANGE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-1061
Practice Address - Country:US
Practice Address - Phone:401-421-5434
Practice Address - Fax:401-421-4633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00412291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1972590Medicaid
RI1972590Medicaid
RI119023804Medicare ID - Type Unspecified