Provider Demographics
NPI:1578725495
Name:COASTAL CARDIOLOGY A MEDICAL CORP
Entity type:Organization
Organization Name:COASTAL CARDIOLOGY A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAMULARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-782-8844
Mailing Address - Street 1:PO BOX 12003
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-2003
Mailing Address - Country:US
Mailing Address - Phone:805-782-8844
Mailing Address - Fax:805-540-5881
Practice Address - Street 1:310 SOUTH HALCYON ROAD STE 105
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3872
Practice Address - Country:US
Practice Address - Phone:805-782-8844
Practice Address - Fax:813-613-2632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23186363AM0700X, 363AM0700X
CAA114658207RI0011X, 207RI0011X
CA207RC0000X, 207UN0901X, 207RC0000X
CAA116056207RC0000X
CAC128646207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068680Medicaid
CAZZZ24859ZOtherBLUE SHIELD
CAWG56853EMedicare PIN
CAZZZ24859ZOtherBLUE SHIELD
CAWG29073DMedicare PIN
CAWG54180DMedicare PIN
CAWA54052EMedicare PIN
CAWA72324BMedicare PIN
CAWG21420DMedicare PIN
CACP1074Medicare PIN
CAWG23388CMedicare PIN
CAWG44009CMedicare PIN
CAWG69997LMedicare PIN
CAWA63687FMedicare PIN
CAWG29696DMedicare PIN
CAW8858AMedicare PIN
CAGR0068680Medicaid