Provider Demographics
NPI:1730138157
Name:EAST COAST RETINA, PA
Entity Type:Organization
Organization Name:EAST COAST RETINA, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-215-3363
Mailing Address - Street 1:8609 MONTAGUE LN
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-4504
Mailing Address - Country:US
Mailing Address - Phone:843-215-3363
Mailing Address - Fax:843-215-7201
Practice Address - Street 1:8609 MONTAGUE LN
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-4504
Practice Address - Country:US
Practice Address - Phone:843-215-3363
Practice Address - Fax:843-215-7201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26821261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4339Medicaid
SC=========OtherTAX ID