Provider Demographics
NPI:1982012829
Name:COASTAL PEDIATRICS
Entity Type:Organization
Organization Name:COASTAL PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGE
Authorized Official - Prefix:MS
Authorized Official - First Name:BOBBIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-347-4677
Mailing Address - Street 1:8030 MYRTLE TRACE DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8945
Mailing Address - Country:US
Mailing Address - Phone:843-347-4677
Mailing Address - Fax:843-347-4678
Practice Address - Street 1:8030 MYRTLE TRACE DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8945
Practice Address - Country:US
Practice Address - Phone:843-347-4677
Practice Address - Fax:843-347-4678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC0593Medicaid