1124161682 NPI number — COASTAL CAROLINA UROLOGY GROUP LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124161682 NPI number — COASTAL CAROLINA UROLOGY GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL CAROLINA UROLOGY GROUP LLC
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:
1124161682
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 440007
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37244-0007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-482-4871
Provider Business Mailing Address Fax Number:
615-261-6052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
HARDEEVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29927-3447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-342-7607
Provider Business Practice Location Address Fax Number:
843-342-7640
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOWE
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
888-482-4871

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  10062233 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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