Provider Demographics
NPI:1801964598
Name:COASTAL PHYSICIANS MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:COASTAL PHYSICIANS MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:MAGDELENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-832-4221
Mailing Address - Street 1:3500 W LOMITA BLVD
Mailing Address - Street 2:NUMBER 203
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505
Mailing Address - Country:US
Mailing Address - Phone:310-534-8164
Mailing Address - Fax:310-534-4267
Practice Address - Street 1:3500 W LOMITA BLVD
Practice Address - Street 2:NUMBER 203
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505
Practice Address - Country:US
Practice Address - Phone:310-534-8164
Practice Address - Fax:310-534-4267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13983Medicare PIN