Provider Demographics
NPI:1295892875
Name:COAST INTERNAL MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:COAST INTERNAL MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-431-3535
Mailing Address - Street 1:10861 CHERRY STREET SUITE 301
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-5403
Mailing Address - Country:US
Mailing Address - Phone:562-431-3535
Mailing Address - Fax:562-431-3535
Practice Address - Street 1:10861 CHERRY STREET
Practice Address - Street 2:SUITE 301
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-5403
Practice Address - Country:US
Practice Address - Phone:562-431-3535
Practice Address - Fax:562-431-6707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090910Medicaid
CAGR0090910Medicaid