Provider Demographics
NPI:1740267574
Name:CENTRAL COAST CHEST CONSULTANTS A MEDICAL CORPORATION
Entity type:Organization
Organization Name:CENTRAL COAST CHEST CONSULTANTS A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-543-4407
Mailing Address - Street 1:PO BOX 12460
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-2460
Mailing Address - Country:US
Mailing Address - Phone:805-548-1142
Mailing Address - Fax:805-234-9985
Practice Address - Street 1:1428 PHILLIPS LN
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2537
Practice Address - Country:US
Practice Address - Phone:805-543-4407
Practice Address - Fax:805-543-4587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62340207R00000X
CA2070377207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ138137ZOtherBLUE SHIELD PIN - SVRMC
184149800OtherUS DOL PIN
CAGR0046460Medicaid
CAZZZ25763ZOtherBLUE SHIELD PIN - PHILLIP
CAZZZ138136ZOtherBLUE SHIELD PIN - FRENCH
CAZZZ13198ZOtherBLUE SHIELD TEMPLETON
184149800OtherUS DOL PIN
CAZZZ138136ZOtherBLUE SHIELD PIN - FRENCH