Provider Demographics
NPI:1043312515
Name:COASTAL GASTROENTEROLOGY ASSOCIATES, PA
Entity type:Organization
Organization Name:COASTAL GASTROENTEROLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KALYANAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SUBRAMANYAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-557-2527
Mailing Address - Street 1:1015 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4052
Mailing Address - Country:US
Mailing Address - Phone:281-557-2527
Mailing Address - Fax:281-557-7203
Practice Address - Street 1:1015 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 1300
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4052
Practice Address - Country:US
Practice Address - Phone:281-557-2527
Practice Address - Fax:281-557-7203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-03
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2226780OtherBCBS - TX - BLUE LINK ID
5283OtherRR MCR GROUP NUMBER
4102895OtherAETNA
P00440059OtherRR MCR
1164493870OtherNPI - INDIVIDUAL
B26780OtherMCR UPIN - INDIVIDUAL
TX114758902OtherTHMP - DR. SUBRAMANYAM
TX114758902OtherTHMP - DR. SUBRAMANYAM