Healthcare Provider Details

I. General information

NPI: 1164578928
Provider Name (Legal Business Name): COASTAL NEUROSCIENCES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HARBOR LANE
SOMERS POINT NJ
08244-2470
US

IV. Provider business mailing address

110 HARBOR LANE
SOMERS POINT NJ
08244-2470
US

V. Phone/Fax

Practice location:
  • Phone: 609-653-9110
  • Fax: 609-653-4105
Mailing address:
  • Phone: 609-653-9110
  • Fax: 609-653-4105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREW S GLASS
Title or Position: PRESIDENT
Credential: MD
Phone: 609-653-9110