Provider Demographics
NPI:1497847917
Name:COAST KIDNEY DISEASE & INTERNAL MEDICINE
Entity Type:Organization
Organization Name:COAST KIDNEY DISEASE & INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ALANNA
Authorized Official - Middle Name:N
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-818-9008
Mailing Address - Street 1:3099 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4308
Mailing Address - Country:US
Mailing Address - Phone:228-818-9008
Mailing Address - Fax:228-818-0750
Practice Address - Street 1:3099 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4308
Practice Address - Country:US
Practice Address - Phone:228-818-9008
Practice Address - Fax:228-818-0750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15918207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty