Healthcare Provider Details

I. General information

NPI: 1417985094
Provider Name (Legal Business Name): COASTAL SPINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 01/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CHURCH RD
MOUNT LAUREL NJ
08054-1110
US

IV. Provider business mailing address

4000 CHURCH RD
MOUNT LAUREL NJ
08054-1110
US

V. Phone/Fax

Practice location:
  • Phone: 856-222-4444
  • Fax:
Mailing address:
  • Phone: 856-222-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARGUERITE ZOLTEK
Title or Position: BILLING DIRECTOR
Credential:
Phone: 856-222-4444