Basic Information
| Provider Information | |||||||||
| NPI: | 1184730749 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL CAROLINA MULTISPECIALTY ASSOCS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9221 UNIVERSITY BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435760700 | ||||||||
| FaxNumber: | 8435760701 | ||||||||
| Practice Location | |||||||||
| Address1: | 9221 UNIVERSITY BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435760700 | ||||||||
| FaxNumber: | 8435760701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | PICKETT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE-PRESIDENT OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6787625037 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GP 4508 | 05 | SC | MEDICAID |