Provider Demographics
NPI:1851680896
Name:COASTAL PEDIATRIC ASSOCIATES, PA
Entity Type:Organization
Organization Name:COASTAL PEDIATRIC ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MCLAURIN
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-573-2535
Mailing Address - Street 1:2051 CHARLIE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5834
Mailing Address - Country:US
Mailing Address - Phone:843-266-4769
Mailing Address - Fax:
Practice Address - Street 1:1952 LONG GROVE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7579
Practice Address - Country:US
Practice Address - Phone:843-284-4262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18368208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4716Medicaid
SCGP4680Medicaid