Provider Demographics
NPI:1497717086
Name:COASTAL CAROLINA OTOLARYNGOLOGY ASSOCIATES,PA
Entity Type:Organization
Organization Name:COASTAL CAROLINA OTOLARYNGOLOGY ASSOCIATES,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-449-6449
Mailing Address - Street 1:3822 MAYFAIR ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-0912
Mailing Address - Country:US
Mailing Address - Phone:843-449-6449
Mailing Address - Fax:843-449-1069
Practice Address - Street 1:3822 MAYFAIR ST
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-0912
Practice Address - Country:US
Practice Address - Phone:843-449-6449
Practice Address - Fax:843-449-1069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0566Medicaid
SC5502Medicare ID - Type Unspecified
SCGP0566Medicaid