Basic Information
| Provider Information | |||||||||
| NPI: | 1881645893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL CARDIOLOGY, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1033 SAINT ANDREWS BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294077156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437236111 | ||||||||
| FaxNumber: | 8437270973 | ||||||||
| Practice Location | |||||||||
| Address1: | 1033 SAINT ANDREWS BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294077156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437236161 | ||||||||
| FaxNumber: | 8437230675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | HENDRY | ||||||||
| AuthorizedOfficialFirstName: | VAN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8433771804 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | PA9570 | 05 | SC | MEDICAID |