Healthcare Provider Details

I. General information

NPI: 1629708821
Provider Name (Legal Business Name): COASTLINE SURGICAL GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PINE ST STE 123
ENGLEWOOD FL
34223-4457
US

IV. Provider business mailing address

900 PINE ST STE 123
ENGLEWOOD FL
34223-4457
US

V. Phone/Fax

Practice location:
  • Phone: 941-786-0790
  • Fax: 941-786-0959
Mailing address:
  • Phone: 941-786-0790
  • Fax: 941-786-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SHEA G JONES
Title or Position: MANAGER
Credential:
Phone: 941-786-0790