Provider Demographics
NPI:1518079102
Name:COASTAL CAROLINA MULTISPECIALTY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:COASTAL CAROLINA MULTISPECIALTY ASSOCIATES, LLC
Other - Org Name:COASTAL CAROLINA SURGICAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FAILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-856-7923
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-372-5426
Mailing Address - Fax:
Practice Address - Street 1:295A MIDLAND PKWY STE 120
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-5901
Practice Address - Country:US
Practice Address - Phone:843-875-8994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL CAROLINA MULTISPECIALTY ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4508Medicaid
SC8566Medicare PIN