Basic Information
| Provider Information | |||||||||
| NPI: | 1811296239 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH COAST GASTROENTEROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100523 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295020523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436695162 | ||||||||
| FaxNumber: | 8436674573 | ||||||||
| Practice Location | |||||||||
| Address1: | 2891 TRICOM ST STE B | ||||||||
| Address2: | |||||||||
| City: | N CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294067110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437182676 | ||||||||
| FaxNumber: | 8437182675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2011 | ||||||||
| LastUpdateDate: | 03/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | PRICE | ||||||||
| AuthorizedOfficialFirstName: | POLLY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8436695162 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 331 | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | GP5658 | 05 | SC | MEDICAID |