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General NPI Number Information
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NPI Number | 1760580104
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Entity Type | Organization
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Legal Business Name | COAST ORTHOPEDIC CENTER PA
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 05/24/2016
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Provider Practice Location Address
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Address Line | 1781 GARDEN ST
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City | TITUSVILLE
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State | FL
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Zip | 32796-3221
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Country | US
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Telephone | 321-269-4300
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Fax | 321-269-7755
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Provider Business Mailing Address
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Address Line | 1781 GARDEN ST
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City | TITUSVILLE
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State | FL
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Zip | 32796-3221
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Country | US
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Telephone | 321-269-4300
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Fax | 321-269-7755
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. JAMES D. GLENN
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Credential | M.D.
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Telephone | 321-269-4300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | ME51090
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License Number State | FL
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