MEDICARE: COASTLINE MEDICAL SERVICES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QS0010X	Sports Medicine (Family Medicine) Physician
2	261QM2500X	Medical Specialty Clinic/Center	ME116308	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003361767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTLINE MEDICAL SERVICES PLLC

Provider Business Mailing Address
First Line	:	208 MARY ESTHER BLVD
Second Line	:
City	:	MARY ESTHER
State	:	FL
Zip	:	32569-1687
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1817 LEWIS TURNER BLVD STE F
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1349
Country	:	US
Telephone Number	:	850-396-1110
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. MICHAEL TAVERNARIS
Credential	:	M.D
Telephone Number	:	850-396-1110

Provider Enumeration Date	:	08/23/2016
Last Update Date	:	09/27/2024

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Directions to “COASTLINE MEDICAL SERVICES PLLC ” Practice Location

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