Provider Demographics
NPI:1174648802
Name:COASTAL CAROLINA PHYSICIAN PRACTICES LLC
Entity Type:Organization
Organization Name:COASTAL CAROLINA PHYSICIAN PRACTICES LLC
Other - Org Name:COASTAL CAROLINA EAR NOSE AND THROAT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIVISION PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8500
Mailing Address - Street 1:1010 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HARDEEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29927-3447
Mailing Address - Country:US
Mailing Address - Phone:843-784-7160
Mailing Address - Fax:843-784-7161
Practice Address - Street 1:1010 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 210
Practice Address - City:HARDEEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29927-3447
Practice Address - Country:US
Practice Address - Phone:843-784-7160
Practice Address - Fax:843-784-7161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18548207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid
SCPENDINGMedicare ID - Type Unspecified