Basic Information
| Provider Information | |||||||||
| NPI: | 1740584770 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHCOAST MEDICAL GROUP P C | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHCOAST PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16029 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314162729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126914100 | ||||||||
| FaxNumber: | 9126914289 | ||||||||
| Practice Location | |||||||||
| Address1: | 1326 EISENHOWER DR BLDG 1 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126913528 | ||||||||
| FaxNumber: | 9126913517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2011 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARRERO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9123033552 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | PHRE009720 | GA | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2128560 | 01 | PK | OTHER | 3000032057A | 05 | GA | MEDICAID |