Provider Demographics
NPI:1326300781
Name:COASTAL CAROLINA PHYSICIAN PRACTICES, LLC
Entity Type:Organization
Organization Name:COASTAL CAROLINA PHYSICIAN PRACTICES, LLC
Other - Org Name:SOUTHERN SURGICAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL CFO, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-265-5009
Mailing Address - Street 1:408 JACKSON AVE E
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:SC
Mailing Address - Zip Code:29924-3602
Mailing Address - Country:US
Mailing Address - Phone:803-943-4003
Mailing Address - Fax:803-943-4701
Practice Address - Street 1:408 JACKSON AVE E
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924-3602
Practice Address - Country:US
Practice Address - Phone:803-943-4003
Practice Address - Fax:803-943-4701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty