Provider Demographics
NPI:1538316575
Name:COASTAL CAROLINA MEDICAL CENTER INC
Entity Type:Organization
Organization Name:COASTAL CAROLINA MEDICAL CENTER INC
Other - Org Name:COASTAL CAROLINA MEDICAL CENTER-ED PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:GROTELUSCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-784-8076
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4342
Practice Address - Street 1:1000 MEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:HARDEEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29927
Practice Address - Country:US
Practice Address - Phone:843-784-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-21
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4209Medicaid
SC9075Medicare PIN
SCDO6726Medicare PIN