Provider Demographics
NPI:1336653708
Name:SOUTHERN COAST PAIN SPECIALISTS
Entity Type:Organization
Organization Name:SOUTHERN COAST PAIN SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:BJ
Authorized Official - Last Name:SCHUYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-476-4702
Mailing Address - Street 1:1055 RIBAUT RD STE 30
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5447
Mailing Address - Country:US
Mailing Address - Phone:843-476-4702
Mailing Address - Fax:843-476-4290
Practice Address - Street 1:1055 RIBAUT RD STE 30
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5447
Practice Address - Country:US
Practice Address - Phone:843-476-4702
Practice Address - Fax:843-476-4290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-21
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35457207LP2900X, 207LP2900X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC354574Medicaid