Provider Demographics
NPI:1699937839
Name:COASTAL PHYSICAL THERAPY & SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:COASTAL PHYSICAL THERAPY & SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JEREMY
Authorized Official - Last Name:BAILS
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, DPT
Authorized Official - Phone:410-749-5050
Mailing Address - Street 1:1502 PEMBERTON DR STE C
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-2475
Mailing Address - Country:US
Mailing Address - Phone:410-749-5050
Mailing Address - Fax:410-749-5057
Practice Address - Street 1:1502 PEMBERTON DR STE C
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-2475
Practice Address - Country:US
Practice Address - Phone:410-749-5050
Practice Address - Fax:410-749-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20434261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD143839ZCMGOtherMEDICARE GROUP PROVIDER NUMBER