Provider Demographics
NPI:1871527838
Name:CENTRAL COAST CARDIOTHORACIC SURGICAL ASSOCIATES-A MEDICAL GROUP
Entity type:Organization
Organization Name:CENTRAL COAST CARDIOTHORACIC SURGICAL ASSOCIATES-A MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-556-6001
Mailing Address - Street 1:911 OAK PARK BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3405
Mailing Address - Country:US
Mailing Address - Phone:805-556-6001
Mailing Address - Fax:805-773-4232
Practice Address - Street 1:911 OAK PARK BLVD
Practice Address - Street 2:STE 102
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3405
Practice Address - Country:US
Practice Address - Phone:805-556-6001
Practice Address - Fax:805-773-4232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071980Medicaid
CAW13876Medicare UPIN