Provider Demographics
NPI:1720301732
Name:COAST FAMILY PHYSICIANS, P.A.
Entity Type:Organization
Organization Name:COAST FAMILY PHYSICIANS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:JUDSON
Authorized Official - Last Name:KITCHINGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-863-6883
Mailing Address - Street 1:PO BOX 899
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-0899
Mailing Address - Country:US
Mailing Address - Phone:228-863-6883
Mailing Address - Fax:228-864-7949
Practice Address - Street 1:186 E OLD PASS RD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-4621
Practice Address - Country:US
Practice Address - Phone:228-863-6883
Practice Address - Fax:228-864-7949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS03606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0123644Medicaid
MSB64511Medicare PIN