Provider Demographics
NPI:1518007681
Name:COASTAL CAROLINA MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:COASTAL CAROLINA MEDICAL CENTER, INC
Other - Org Name:COASTAL MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP OF OUTPATIENT SERVICES, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BURTNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2153
Mailing Address - Street 1:PO BOX 741261
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1261
Mailing Address - Country:US
Mailing Address - Phone:843-784-3101
Mailing Address - Fax:843-784-5313
Practice Address - Street 1:10911 NORTH JACOB SMART BLVD
Practice Address - Street 2:#D
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-2729
Practice Address - Country:US
Practice Address - Phone:843-784-3101
Practice Address - Fax:843-784-5313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
423450Medicare Oscar/Certification