Basic Information
| Provider Information | |||||||||
| NPI: | 1306516208 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERCOASTAL MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 943 S BENEVA RD STE 306 | ||||||||
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| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342322473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419551108 | ||||||||
| FaxNumber: | 9419544440 | ||||||||
| Practice Location | |||||||||
| Address1: | 11715 RANGELAND PKWY | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342119529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9415380001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2021 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | STEELE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9419535213 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.