Provider Demographics
NPI:1366560435
Name:COASTAL EAR, NOSE AND THROAT, HEAD AND NECK SURGERY ASSOCIATES, PLLC
Entity type:Organization
Organization Name:COASTAL EAR, NOSE AND THROAT, HEAD AND NECK SURGERY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-863-6617
Mailing Address - Street 1:407 SECURITY SQ
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-1922
Mailing Address - Country:US
Mailing Address - Phone:228-896-1987
Mailing Address - Fax:228-896-1315
Practice Address - Street 1:407 SECURITY SQ
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1922
Practice Address - Country:US
Practice Address - Phone:228-896-1987
Practice Address - Fax:228-896-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC02361Medicare UPIN