1821142720 NPI number — COASTAL EYE GROUP, P.C.

Table of content: DR. GREGORY JOHN KENNEY MD (NPI 1588628507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821142720 NPI number — COASTAL EYE GROUP, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL EYE GROUP, P.C.
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:
Provider Other Organization Name Type Code:
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:
1821142720
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 HIGHMARKET ST STE 200
Provider Second Line Business Mailing Address:
P.O. BOX 2900
Provider Business Mailing Address City Name:
GEORGETOWN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29440-3227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-546-8421
Provider Business Mailing Address Fax Number:
843-652-1173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 HIGHMARKET ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29440-3227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-546-8421
Provider Business Practice Location Address Fax Number:
843-652-1173
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RATELIFF
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
843-546-8421

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PC0502 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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