Provider Demographics
NPI:1003846403
Name:CENTRAL COAST NEUROLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:CENTRAL COAST NEUROLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GENEVIEVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-379-6100
Mailing Address - Street 1:2250 HAYES ST STE 206
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-1078
Mailing Address - Country:US
Mailing Address - Phone:415-379-6100
Mailing Address - Fax:
Practice Address - Street 1:2250 HAYES ST STE 206
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1078
Practice Address - Country:US
Practice Address - Phone:415-379-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21539032084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15124Medicare PIN
CACH5904Medicare PIN