Provider Demographics
NPI:1134214331
Name:COASTAL CHRONIC PAIN SERVICES, PLLC
Entity type:Organization
Organization Name:COASTAL CHRONIC PAIN SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-831-0204
Mailing Address - Street 1:15190 COMMUNITY RD STE 230B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3483
Mailing Address - Country:US
Mailing Address - Phone:228-831-0050
Mailing Address - Fax:228-831-1121
Practice Address - Street 1:15190 COMMUNITY RD STE 230B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3483
Practice Address - Country:US
Practice Address - Phone:228-831-0050
Practice Address - Fax:228-831-1121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GULFPORT ANESTHESIA SERVICES, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-04
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02403Medicare ID - Type Unspecified