Healthcare Provider Details

I. General information

NPI: 1003361767
Provider Name (Legal Business Name): COASTLINE MEDICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 LEWIS TURNER BLVD STE F
FORT WALTON BEACH FL
32547-1349
US

IV. Provider business mailing address

208 MARY ESTHER BLVD
MARY ESTHER FL
32569-1687
US

V. Phone/Fax

Practice location:
  • Phone: 850-396-1110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberME116308
License Number StateFL

VIII. Authorized Official

Name: DR. MICHAEL TAVERNARIS
Title or Position: PHYSICIAN
Credential: M.D
Phone: 850-396-1110