Provider Demographics
NPI:1245291988
Name:COASTAL ORTHOPAEDICS & SPORTS MEDICINE CENTER
Entity type:Organization
Organization Name:COASTAL ORTHOPAEDICS & SPORTS MEDICINE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JESUS
Authorized Official - Last Name:ROSSARIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-335-5300
Mailing Address - Street 1:7710 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-2320
Mailing Address - Country:US
Mailing Address - Phone:772-335-5300
Mailing Address - Fax:772-873-3004
Practice Address - Street 1:7710 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-2320
Practice Address - Country:US
Practice Address - Phone:772-335-5300
Practice Address - Fax:772-873-3004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33747OtherBCBS GROUP
FL0721200001Medicare NSC
K0665Medicare PIN