Provider Demographics
NPI:1639281298
Name:COASTAL PAIN CARE PHYSICIANS, P.A.
Entity type:Organization
Organization Name:COASTAL PAIN CARE PHYSICIANS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SOMORI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-645-9180
Mailing Address - Street 1:1606 SAVANNAH RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-1656
Mailing Address - Country:US
Mailing Address - Phone:302-645-2664
Mailing Address - Fax:302-645-2774
Practice Address - Street 1:1606 SAVANNAH RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1656
Practice Address - Country:US
Practice Address - Phone:302-645-2664
Practice Address - Fax:302-645-2774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0006005174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001194901Medicaid
DE0001194901Medicaid
00B101C34Medicare ID - Type Unspecified