Provider Demographics
NPI:1932101821
Name:CORADI, SCOTT ANTHONY (DO)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ANTHONY
Last Name:CORADI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 OLEANDER DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5741
Mailing Address - Country:US
Mailing Address - Phone:843-497-5929
Mailing Address - Fax:
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-497-5929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC879207P00000X
SC879207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC008798Medicaid
SC879OtherLICENSE
SCAA10999326Medicare PIN