Basic Information
| Provider Information | |||||||||
| NPI: | 1528101664 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL CAROLINA UROLOGY GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 440007 | ||||||||
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| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372440007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884824871 | ||||||||
| FaxNumber: | 6152616052 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 RIBAUT RD | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435247607 | ||||||||
| FaxNumber: | 8435246737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 03/31/2015 | ||||||||
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| AuthorizedOfficialLastName: | HOWE | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 8884824871 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 200011 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | CG7000 | 01 | SC | RR MEDICARE | OTHER |