Provider Demographics
NPI:1134894009
Name:COASTAL DIAGNOSTIC TESTING GROUP INC
Entity type:Organization
Organization Name:COASTAL DIAGNOSTIC TESTING GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MEHRDAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GERAMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-756-7710
Mailing Address - Street 1:1957 THOMPSON RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420
Mailing Address - Country:US
Mailing Address - Phone:541-756-7710
Mailing Address - Fax:541-756-7699
Practice Address - Street 1:615 CHETCO AVE
Practice Address - Street 2:STE A
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415
Practice Address - Country:US
Practice Address - Phone:541-412-9556
Practice Address - Fax:541-756-7699
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL DIAGNOSTIC TESTING GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-12
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500719439Medicaid