1093097396 NPI number — RENEWALMD BLUFFTON

Table of content: (NPI 1093097396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093097396 NPI number — RENEWALMD BLUFFTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENEWALMD BLUFFTON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COASTAL EMPIRE PLASTIC SURGERY, PC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093097396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 MOHAWK ST STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31419-1772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-920-2090
Provider Business Mailing Address Fax Number:
912-920-4114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 SHERINGTON DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BLUFFTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-920-2090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KEEL
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
PATIENT ACCOUNT MANAGER
Authorized Official Telephone Number:
912-920-5624

Provider Taxonomy Codes

  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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