Healthcare Provider Details

I. General information

NPI: 1740267574
Provider Name (Legal Business Name): CENTRAL COAST CHEST CONSULTANTS A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 PHILLIPS LN SUITE 203
SAN LUIS OBISPO CA
93401-2537
US

IV. Provider business mailing address

PO BOX 12460
SAN LUIS OBISPO CA
93406-2460
US

V. Phone/Fax

Practice location:
  • Phone: 805-543-4407
  • Fax: 805-543-4587
Mailing address:
  • Phone: 805-548-1142
  • Fax: 805-234-9985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA62340
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2070377
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2070377
License Number StateCA

VIII. Authorized Official

Name: MICHAEL J RYAN
Title or Position: PRESIDENT
Credential: MD
Phone: 805-543-4407