1922109701 NPI number — COASTAL ORTHOPEDIC ASSOCIATES, PA

Table of content: (NPI 1922109701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922109701 NPI number — COASTAL ORTHOPEDIC ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL ORTHOPEDIC ASSOCIATES, PA
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:
1922109701
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2376 CYPRESS CIRCLE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29526-8920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-347-7222
Provider Business Mailing Address Fax Number:
843-347-3305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2376 CYPRESS CIRCLE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29526-8920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-347-7222
Provider Business Practice Location Address Fax Number:
843-347-3305
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MEARES
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
ADMINISTRATIVE ASSISTANT
Authorized Official Telephone Number:
843-234-7857

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DM0418 . This is a "DME MEDICAID" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 0313730001 . This is a "DME MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 42D0675833 . This is a "CLIA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: PA7162 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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