Basic Information
| Provider Information | |||||||||
| NPI: | 1467733774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL PAIN SOLUTIONS, INC. | ||||||||
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| OtherOrganizationName: | ANESTHESIA OF THE TREASURE COAST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 REMITTANCE DR | ||||||||
| Address2: | SUITE 6633 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606756633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722232115 | ||||||||
| FaxNumber: | 7722230887 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 SE OCEAN BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349963332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722232115 | ||||||||
| FaxNumber: | 7722230887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2011 | ||||||||
| LastUpdateDate: | 12/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | LEVINE | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7723377676 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 002V3 | 01 | FL | BCBS OF FLORIDA | OTHER |