Basic Information
| Provider Information | |||||||||
| NPI: | 1861745119 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHCOAST MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15849 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314162549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123033552 | ||||||||
| FaxNumber: | 9123033506 | ||||||||
| Practice Location | |||||||||
| Address1: | 1326 EISENHOWER DR | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314063928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126914100 | ||||||||
| FaxNumber: | 9126914209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2012 | ||||||||
| LastUpdateDate: | 10/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | MARRERO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9123033552 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 020999 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 038715 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207W00000X | 026247 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 2084N0400X | 064752 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085R0202X | 039937 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 363A00000X | 5306 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | RN077768 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RN0300X | 047425 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.