MEDICARE: COASTAL ANESTHESIOLOGY CONSULTANTS, LLC

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	207L00000X	Anesthesiology Physician		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	98677	OTHER		BCBS OF FLORIDA

General Provider Information

NPI Number	:	1366608796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL ANESTHESIOLOGY CONSULTANTS, LLC

Provider Business Mailing Address
First Line	:	5565 CENTERVIEW DR STE 107
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27606-3563
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 HEALTH PARK BLVD
Second Line	:
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-5784
Country	:	US
Telephone Number	:	904-819-4478
Fax Number	:	904-819-4993

Authorized Official
Title or Position	:	OFFICER
Name	:	KATHLEEN KONDAS
Credential	:
Telephone Number	:	877-328-1119

Provider Enumeration Date	:	08/05/2008
Last Update Date	:	07/22/2021

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Directions to “COASTAL ANESTHESIOLOGY CONSULTANTS, LLC ” Practice Location

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