Provider Demographics
NPI:1003096058
Name:CAROLINA COASTAL PLASTIC AND RECONSTRUCTIVE SURGERY, INC.
Entity Type:Organization
Organization Name:CAROLINA COASTAL PLASTIC AND RECONSTRUCTIVE SURGERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:843-448-9977
Mailing Address - Street 1:1275 21ST AVE N
Mailing Address - Street 2:BUILD # 1
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-7429
Mailing Address - Country:US
Mailing Address - Phone:843-448-9977
Mailing Address - Fax:843-626-7755
Practice Address - Street 1:1275 21ST AVE N
Practice Address - Street 2:BUILD #1
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-7429
Practice Address - Country:US
Practice Address - Phone:843-448-9977
Practice Address - Fax:843-626-7755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCE13723Medicare UPIN