Provider Demographics
NPI:1417900556
Name:COASTAL EMPIRE IMAGING, LLC
Entity Type:Organization
Organization Name:COASTAL EMPIRE IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-354-4164
Mailing Address - Street 1:PO BOX 15479
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-2179
Mailing Address - Country:US
Mailing Address - Phone:912-354-4164
Mailing Address - Fax:912-303-4940
Practice Address - Street 1:1000 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:HARDEEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29927-3446
Practice Address - Country:US
Practice Address - Phone:912-354-4164
Practice Address - Fax:912-303-4940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4519Medicaid
GA10069441OtherAMERIGROUP
GADE7906OtherRAILROAD MEDICARE
SCDF1119OtherRAILROAD MEDICARE
GA10069441OtherAMERIGROUP
SCGP4519Medicaid
GAGRP7731Medicare PIN
SC=========OtherBCBSSC