Provider Demographics
NPI:1417368853
Name:COASTAL RHEUMATOLOGY, LLC
Entity Type:Organization
Organization Name:COASTAL RHEUMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:DEGENHARDT
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:912-349-4227
Mailing Address - Street 1:4849 PAULSEN ST
Mailing Address - Street 2:SUITE 312
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4423
Mailing Address - Country:US
Mailing Address - Phone:912-349-4227
Mailing Address - Fax:
Practice Address - Street 1:4849 PAULSEN ST
Practice Address - Street 2:SUITE 312
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4423
Practice Address - Country:US
Practice Address - Phone:912-349-4227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-19
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G709181Medicare PIN