Provider Demographics
NPI:1699707885
Name:COASTAL RADIATION ONCOLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:COASTAL RADIATION ONCOLOGY MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-648-5191
Mailing Address - Street 1:PO BOX 849697
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-9697
Mailing Address - Country:US
Mailing Address - Phone:805-648-5191
Mailing Address - Fax:805-648-3458
Practice Address - Street 1:1069 LOS PALOS DR
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3916
Practice Address - Country:US
Practice Address - Phone:831-758-2724
Practice Address - Fax:831-758-1531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR00087200Medicaid
CAGR00087200Medicaid