Provider Demographics
NPI:1962738567
Name:COASTAL INTERVENTIONAL PAIN MANAGEMENT LLC
Entity type:Organization
Organization Name:COASTAL INTERVENTIONAL PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-822-7000
Mailing Address - Street 1:1099 5TH AVE N
Mailing Address - Street 2:STE 320
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1469
Mailing Address - Country:US
Mailing Address - Phone:727-822-7000
Mailing Address - Fax:727-822-7001
Practice Address - Street 1:1099 5TH AVE N
Practice Address - Street 2:STE 320
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1469
Practice Address - Country:US
Practice Address - Phone:727-822-7000
Practice Address - Fax:727-822-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-02
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34087OtherBS FLORIDA
FLG26795Medicare UPIN