1104393214 NPI number — COASTAL CONCIERGE MEDICINE AND AESTHETICS

Table of content: (NPI 1104393214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104393214 NPI number — COASTAL CONCIERGE MEDICINE AND AESTHETICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL CONCIERGE MEDICINE AND AESTHETICS
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:
DAVID WEITZMAN MD
Provider Other Organization Name Type Code:
3
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:
1104393214
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4420 OLEANDER DR STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29577-5720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-491-3007
Provider Business Mailing Address Fax Number:
888-895-4537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
802 41ST AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29582-5155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-491-3007
Provider Business Practice Location Address Fax Number:
888-895-4537
Provider Enumeration Date:
10/26/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WEITZMAN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN OWNER
Authorized Official Telephone Number:
843-491-3007

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207QA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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