Provider Demographics
NPI:1104393214
Name:COASTAL CONCIERGE MEDICINE AND AESTHETICS
Entity Type:Organization
Organization Name:COASTAL CONCIERGE MEDICINE AND AESTHETICS
Other - Org Name:DAVID WEITZMAN MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WEITZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-491-3007
Mailing Address - Street 1:4420 OLEANDER DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5720
Mailing Address - Country:US
Mailing Address - Phone:843-491-3007
Mailing Address - Fax:888-895-4537
Practice Address - Street 1:802 41ST AVE S
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-5155
Practice Address - Country:US
Practice Address - Phone:843-491-3007
Practice Address - Fax:888-895-4537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-26
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC391356Medicaid