=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235321340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL OBSTETRICS & GYNECOLOGY ASSOCIATES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2007
-----------------------------------------------------
Last Update Date | 01/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 72 W JIM LEEDS RD SUITE 2500 STOCKTON MEDICAL BUILDING
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08240-0836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-652-6600
-----------------------------------------------------
Fax | 609-652-1267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 386
-----------------------------------------------------
City | LINWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08221-0386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-652-6600
-----------------------------------------------------
Fax | 609-652-1267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. EDWARD L SUNG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 609-652-6600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | MA029589
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------