Provider Demographics
NPI:1306971833
Name:COAST MULTI-SPECIALTY MEDICAL GROUP P.A
Entity type:Organization
Organization Name:COAST MULTI-SPECIALTY MEDICAL GROUP P.A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:TROTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-758-1965
Mailing Address - Street 1:PO BOX 1762
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-1762
Mailing Address - Country:US
Mailing Address - Phone:386-758-1965
Mailing Address - Fax:386-758-6923
Practice Address - Street 1:480 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5269
Practice Address - Country:US
Practice Address - Phone:386-758-1965
Practice Address - Fax:386-758-6923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80264207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2456OtherMEDICARE GROUP PTAN
FL51900ZMedicare PIN