=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346277860
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL ORTHOPEDIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2006
-----------------------------------------------------
Last Update Date | 12/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 99 BAHIA VISTA DR
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-3617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-678-2678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 99 BAHIA VISTA DR
-----------------------------------------------------
City | NICEVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32578-3617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-678-2678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MICHELLE GLENN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-678-2678
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | ME0063572
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------