Provider Demographics
NPI:1679554752
Name:COASTAL CAROLINA NEPHROLOGY LLC
Entity Type:Organization
Organization Name:COASTAL CAROLINA NEPHROLOGY LLC
Other - Org Name:TRIDENT NEPHROLOGY LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:R
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-554-9313
Mailing Address - Street 1:1938-A CHARLIE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5837
Mailing Address - Country:US
Mailing Address - Phone:843-554-9313
Mailing Address - Fax:843-744-5961
Practice Address - Street 1:1938-A CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5837
Practice Address - Country:US
Practice Address - Phone:843-554-9313
Practice Address - Fax:843-744-5961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2007-08-29
Deactivation Date:2006-03-03
Deactivation Code:
Reactivation Date:2007-08-29
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8172OtherMEDICARE GROUP
GP2967OtherMEDICAID GROUP