Provider Demographics
NPI:1689836504
Name:COASTAL CARDIOLOGY A MEDICAL CORP
Entity type:Organization
Organization Name:COASTAL CARDIOLOGY A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAMULARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-782-8844
Mailing Address - Street 1:PO BOX 12003
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-2003
Mailing Address - Country:US
Mailing Address - Phone:805-782-8844
Mailing Address - Fax:805-540-5881
Practice Address - Street 1:295 POSADA LANE SUITE A
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-4055
Practice Address - Country:US
Practice Address - Phone:805-782-8844
Practice Address - Fax:813-613-2635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23186363AM0700X
CAG69997207RI0011X, 207RI0011X
CAG44009207RC0000X, 207RC0000X
CAA99253207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068680Medicaid
CACP1074OtherRR MEDICARE
CAZZZ40450ZOtherBLUE SHIELD
CAWG54180FMedicare PIN
CAWG21420BMedicare PIN
CAWG58530DMedicare PIN
CAWG44009EMedicare PIN
CABM907UMedicare UPIN
CAWG23388EMedicare PIN
CAWG29696FMedicare PIN
CAFD384XMedicare UPIN
CAAM401XMedicare UPIN
CAWG69997NMedicare PIN
CAZZZ40450ZOtherBLUE SHIELD
CACP1074OtherRR MEDICARE
CAWG29073FMedicare PIN