Provider Demographics
NPI:1083777486
Name:COASTAL GRAND OBGYN PC
Entity Type:Organization
Organization Name:COASTAL GRAND OBGYN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIELVOGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-421-8200
Mailing Address - Street 1:1021 MEDICAL CIR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4619
Mailing Address - Country:US
Mailing Address - Phone:843-421-8200
Mailing Address - Fax:843-839-3634
Practice Address - Street 1:1021 MEDICAL CIR
Practice Address - Street 2:SUITE 250
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4619
Practice Address - Country:US
Practice Address - Phone:843-421-8200
Practice Address - Fax:843-839-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC222100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4188Medicaid
SCH42529Medicare UPIN