Provider Demographics
NPI:1952525859
Name:COASTLINE MEDICAL CENTER, PLLC
Entity Type:Organization
Organization Name:COASTLINE MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NGUYEN
Authorized Official - Middle Name:PHONG
Authorized Official - Last Name:HUYNH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:228-396-0333
Mailing Address - Street 1:10536 AUTO MALL PKWY
Mailing Address - Street 2:A
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-3742
Mailing Address - Country:US
Mailing Address - Phone:228-396-0333
Mailing Address - Fax:228-396-4060
Practice Address - Street 1:10536 AUTO MALL PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-3742
Practice Address - Country:US
Practice Address - Phone:228-396-0333
Practice Address - Fax:228-396-4060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19050207R00000X
MS19541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1457462954OtherNPI FOR DR. HUYNH
MS1982618310OtherNPI FOR DR. LE
MS1457462954OtherNPI FOR DR. HUYNH
MSI44088Medicare UPIN
MSC03394Medicare ID - Type UnspecifiedGROUP NUMBER