Provider Demographics
NPI:1457358434
Name:COASTAL NEUROLOGY, INC.
Entity type:Organization
Organization Name:COASTAL NEUROLOGY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:386-788-2300
Mailing Address - Street 1:725 W GRANADA BLVD
Mailing Address - Street 2:SUITE 22
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-788-2300
Mailing Address - Fax:386-944-6622
Practice Address - Street 1:725 W GRANADA BLVD
Practice Address - Street 2:SUITE 22
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-788-2300
Practice Address - Fax:386-944-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84820208VP0014X
FLPA1823363AM0700X
2081P2900X
FLOS57742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE60482OtherINDIVIDUAL-BENEZETTE
FL45556Medicare ID - Type UnspecifiedGROUP
FL80352YMedicare ID - Type UnspecifiedINDIVIDUAL BENEZETTE
FL6294560001Medicare NSC
FLE60482OtherINDIVIDUAL-BENEZETTE
FLT95212Medicare UPIN