MEDICARE: COASTSIDE FAMILY MEDICAL CLINIC, INC

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	207Q00000X	Family Medicine Physician

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	:	1508916628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTSIDE FAMILY MEDICAL CLINIC, INC

Provider Business Mailing Address
First Line	:	225 CABRILLO HWY S STE 100A
Second Line	:
City	:	HALF MOON BAY
State	:	CA
Zip	:	94019-1738
Country	:	US
Telephone Number	:	650-712-7330
Fax Number	:	650-726-9317

Provider Business Practice Location Address
First Line	:	225 CABRILLO HWY S STE 100A
Second Line	:
City	:	HALF MOON BAY
State	:	CA
Zip	:	94019-1738
Country	:	US
Telephone Number	:	650-712-7330
Fax Number	:	650-726-9317

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. ROBERT V HARLESS
Credential	:
Telephone Number	:	650-712-7330

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	08/22/2020

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