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General NPI Number Information
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NPI Number | 1003361767
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Entity Type | Organization
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Legal Business Name | COASTLINE MEDICAL SERVICES PLLC
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Dates
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Enumeration Date | 08/23/2016
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Last Update Date | 09/27/2024
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Provider Practice Location Address
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Address Line | 1817 LEWIS TURNER BLVD STE F
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-1349
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Country | US
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Telephone | 850-396-1110
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Fax |
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Provider Business Mailing Address
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Address Line | 208 MARY ESTHER BLVD
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City | MARY ESTHER
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State | FL
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Zip | 32569-1687
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MICHAEL TAVERNARIS
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Credential | M.D
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Telephone | 850-396-1110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | ME116308
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License Number State | FL
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