Provider Demographics
NPI:1811028558
Name:COASTAL HEAD & NECK ASSOCIATES, PC
Entity Type:Organization
Organization Name:COASTAL HEAD & NECK ASSOCIATES, PC
Other - Org Name:KENNETH C FLETCHER JR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:FLETCHER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:912-466-8899
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31521-0130
Mailing Address - Country:US
Mailing Address - Phone:912-466-8899
Mailing Address - Fax:912-466-8887
Practice Address - Street 1:1107 GLOUCESTER ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-7053
Practice Address - Country:US
Practice Address - Phone:912-466-8899
Practice Address - Fax:912-466-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057614207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI57944Medicare UPIN
GA04BDCSBMedicare ID - Type Unspecified