Provider Demographics
NPI:1093586885
Name:EAST COOPER PHYSICIAN GROUP LLC
Entity Type:Organization
Organization Name:EAST COOPER PHYSICIAN GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, NOVANT HEALTH SOUTH CAROLINA HO
Authorized Official - Prefix:
Authorized Official - First Name:CURT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-384-7811
Mailing Address - Street 1:2085 FRONTIS PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:851 LEONARD FULGHUM DR STE 101
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3793
Practice Address - Country:US
Practice Address - Phone:843-884-2133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies