1679554752 NPI number — COASTAL CAROLINA NEPHROLOGY LLC

Table of content: (NPI 1679554752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679554752 NPI number — COASTAL CAROLINA NEPHROLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL CAROLINA NEPHROLOGY 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:
1679554752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/03/2006
NPI Reactivation Date:
08/29/2007

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1938-A CHARLIE HALL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29414-5837
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-554-9313
Provider Business Mailing Address Fax Number:
843-744-5961

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1938-A CHARLIE HALL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29414-5837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-554-9313
Provider Business Practice Location Address Fax Number:
843-744-5961
Provider Enumeration Date:
11/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
STEWART
Authorized Official First Name:
LISA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
843-554-9313

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8172 . This is a "MEDICARE GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: GP2967 . This is a "MEDICAID GROUP" identifier . This identifiers is of the category "OTHER".




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