Provider Demographics
NPI:1609813179
Name:COASTAL ANESTHESIA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:COASTAL ANESTHESIA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGGIONCALDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-692-1721
Mailing Address - Street 1:PO BOX 1792
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-1792
Mailing Address - Country:US
Mailing Address - Phone:843-692-1721
Mailing Address - Fax:
Practice Address - Street 1:809 82ND PARKWAY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-692-1062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3330Medicaid
SC7226Medicare PIN