Provider Demographics
NPI: | 1467451922 |
---|---|
Name: | SOUTHCOAST MEDICAL GROUP, LLC |
Entity Type: | Organization |
Organization Name: | SOUTHCOAST MEDICAL GROUP, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | ADMINISTRATOR |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | JOHN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MARRERO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 912-303-3552 |
Mailing Address - Street 1: | PO BOX 15849 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAVANNAH |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 31416-2549 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 912-303-3552 |
Mailing Address - Fax: | 912-303-3506 |
Practice Address - Street 1: | 330 BENEFIELD DR |
Practice Address - Street 2: | |
Practice Address - City: | SAVANNAH |
Practice Address - State: | GA |
Practice Address - Zip Code: | 31406-2604 |
Practice Address - Country: | US |
Practice Address - Phone: | 912-303-3552 |
Practice Address - Fax: | 912-303-3506 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-07-18 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 207Q00000X, 207R00000X, 207RC0000X, 207RI0200X, 207RP1001X, 207W00000X, 208000000X, 2085R0202X, 225100000X, 363A00000X, 363L00000X | |
GA | 047425 | 207RN0300X |
GA | 022482 | 207V00000X |
GA | 064752 | 2084N0400X |
GA | 021614 | 208600000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 909802000 | Medicaid | |
SC | GPA3131 | Medicaid | |
SC | GPA643 | Medicaid | |
SC | GPA3131 | Medicaid | |
SC | GPA3131 | Medicaid | |
FL | 909802000 | Medicaid |