Healthcare Provider Details

I. General information

NPI: 1518548627
Provider Name (Legal Business Name): COASTAL MEDICAL ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2021
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

141 LONGWATER DR
NORWELL MA
02061-1632
US

V. Phone/Fax

Practice location:
  • Phone: 781-624-8000
  • Fax:
Mailing address:
  • Phone: 781-681-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207LH0002X
TaxonomyHospice and Palliative Medicine (Anesthesiology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JACLYN VALANZOLA
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 781-681-0384