MEDICARE: COASTAL CARDIOVASCULAR INSTITUTE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0011X	Interventional Cardiology Physician	A62602	CA

General Provider Information

NPI Number	:	1982005195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CARDIOVASCULAR INSTITUTE, INC.

Provider Business Mailing Address
First Line	:	25301 CABOT RD STE 104
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-5511
Country	:	US
Telephone Number	:	949-499-8080
Fax Number	:	949-499-8082

Provider Business Practice Location Address
First Line	:	25301 CABOT RD STE 104
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-5511
Country	:	US
Telephone Number	:	949-499-8080
Fax Number	:	949-499-8082

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	DR. MICHAEL DOUGLAS MORAN
Credential	:	M.D.
Telephone Number	:	949-499-8080

Provider Enumeration Date	:	09/07/2014
Last Update Date	:	09/07/2014

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