{
"Npi": {
"NPI": "1003361767",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "COASTLINE MEDICAL SERVICES PLLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "208 MARY ESTHER BLVD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "MARY ESTHER",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32569-1687",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": null,
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1817 LEWIS TURNER BLVD STE F",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "FORT WALTON BEACH",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "32547-1349",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "850-396-1110",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "08/23/2016",
"LastUpdateDate": "09/27/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "TAVERNARIS",
"AuthorizedOfficialFirstName": "MICHAEL",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PHYSICIAN",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "M.D",
"AuthorizedOfficialTelephoneNumber": "850-396-1110",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "207QS0010X",
"TaxonomyName": "Sports Medicine (Family Medicine) Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "261QM2500X",
"TaxonomyName": "Medical Specialty Clinic/Center",
"LicenseNumber": "ME116308",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}