Healthcare Provider Details

I. General information

NPI: 1932175684
Provider Name (Legal Business Name): COASTAL MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FOGG RD
WEYMOUTH MA
02190-2432
US

IV. Provider business mailing address

55 FOGG RD
WEYMOUTH MA
02190-2432
US

V. Phone/Fax

Practice location:
  • Phone: 781-340-4293
  • Fax: 781-340-3782
Mailing address:
  • Phone: 781-624-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIANNE CAPUTO
Title or Position: PROVIDER ENROLLMENT SUPERVISOR
Credential:
Phone: 781-792-4136