Provider Demographics
NPI:1811076896
Name:CENTRAL COAST INTERNAL MEDICINE, P.C.
Entity type:Organization
Organization Name:CENTRAL COAST INTERNAL MEDICINE, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-265-2007
Mailing Address - Street 1:775 SW 9TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-4895
Mailing Address - Country:US
Mailing Address - Phone:541-265-2007
Mailing Address - Fax:541-265-3533
Practice Address - Street 1:775 SW 9TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4895
Practice Address - Country:US
Practice Address - Phone:541-265-2007
Practice Address - Fax:541-265-3533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR214437Medicaid
ORCO3602OtherRR MEDICARE
OR214437Medicaid