MEDICARE: COASTAL VASCULAR AND INTERVENTIONAL PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	2085R0202X	Diagnostic Radiology Physician
2	2085R0204X	Vascular & Interventional Radiology Physician
3	2086S0129X	Vascular Surgery Physician

General Provider Information

NPI Number	:	1912576851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL VASCULAR AND INTERVENTIONAL PLLC

Provider Business Mailing Address
First Line	:	PO BOX 11982
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32524-1982
Country	:	US
Telephone Number	:	850-479-1805
Fax Number	:	850-479-1829

Provider Business Practice Location Address
First Line	:	4012 COMMONS DR W STE 110
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-8424
Country	:	US
Telephone Number	:	850-479-1805
Fax Number	:	850-479-1829

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DANELLE FISCHER
Credential	:
Telephone Number	:	850-479-1805

Provider Enumeration Date	:	06/24/2021
Last Update Date	:	06/24/2021

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