Provider Demographics
NPI:1720471261
Name:PACIFIC COAST MEDICAL GROUP COMPANY
Entity Type:Organization
Organization Name:PACIFIC COAST MEDICAL GROUP COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAILESH
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTHARI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-904-7564
Mailing Address - Street 1:3060 PEACHTREE RD NW
Mailing Address - Street 2:SUITE 965
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2234
Mailing Address - Country:US
Mailing Address - Phone:678-904-7564
Mailing Address - Fax:
Practice Address - Street 1:315 BOULEVARD NE
Practice Address - Street 2:SUITE 555
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1200
Practice Address - Country:US
Practice Address - Phone:678-904-7564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0338012083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty