1255192308 NPI number — EAST COOPER PHYSICIAN 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 1255192308 NPI number — EAST COOPER PHYSICIAN GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST COOPER PHYSICIAN 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:
6
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:
1255192308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37642
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-1218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 ISLAND PARK DR UNIT 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANIEL ISLAND
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29492-2902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-380-9330
Provider Business Practice Location Address Fax Number:
843-380-8212
Provider Enumeration Date:
01/17/2024

Additional Information

Authorized Official

Authorized Official Last Name:
ROGERS
Authorized Official First Name:
DOREATHA
Authorized Official Middle Name:
Authorized Official Title or Position:
RCS MANAGER
Authorized Official Telephone Number:
980-302-7992

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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