Provider Demographics
NPI:1659458966
Name:COASTAL GYNECOLOGY AND OBSTETRICS PA
Entity Type:Organization
Organization Name:COASTAL GYNECOLOGY AND OBSTETRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:BOATWRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-571-0200
Mailing Address - Street 1:PO BOX 81060
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29416-1060
Mailing Address - Country:US
Mailing Address - Phone:843-571-0200
Mailing Address - Fax:866-848-8485
Practice Address - Street 1:2093 HENRY TECKLENBURG DR
Practice Address - Street 2:SUITE 304 EAST
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5741
Practice Address - Country:US
Practice Address - Phone:843-571-0200
Practice Address - Fax:866-848-8485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12402207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1725Medicaid
SCB91917Medicare UPIN
SCGP1725Medicaid