Provider Demographics
NPI:1306516208
Name:INTERCOASTAL MEDICAL GROUP INC
Entity type:Organization
Organization Name:INTERCOASTAL MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STEELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-953-5213
Mailing Address - Street 1:943 S BENEVA RD STE 306
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-2473
Mailing Address - Country:US
Mailing Address - Phone:941-955-1108
Mailing Address - Fax:941-954-4440
Practice Address - Street 1:11715 RANGELAND PKWY
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34211-9529
Practice Address - Country:US
Practice Address - Phone:941-538-0001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty