Provider Demographics
NPI:1104234194
Name:COASTAL VASCULAR MEDICINE INC
Entity type:Organization
Organization Name:COASTAL VASCULAR MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EHAB
Authorized Official - Middle Name:NABIL HANNA
Authorized Official - Last Name:MADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-631-6002
Mailing Address - Street 1:320 SUPERIOR AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2778
Mailing Address - Country:US
Mailing Address - Phone:949-631-6002
Mailing Address - Fax:949-631-6982
Practice Address - Street 1:320 SUPERIOR AVE STE 250
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2778
Practice Address - Country:US
Practice Address - Phone:949-631-6002
Practice Address - Fax:949-631-6982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X, 174400000X, 261Q00000X
CA10166207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty