Provider Demographics
NPI:1184730749
Name:COASTAL CAROLINA MULTISPECIALTY ASSOCS, LLC
Entity type:Organization
Organization Name:COASTAL CAROLINA MULTISPECIALTY ASSOCS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-762-5037
Mailing Address - Street 1:9221 UNIVERSITY BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9148
Mailing Address - Country:US
Mailing Address - Phone:843-576-0700
Mailing Address - Fax:843-576-0701
Practice Address - Street 1:9221 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9148
Practice Address - Country:US
Practice Address - Phone:843-576-0700
Practice Address - Fax:843-576-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP 4508Medicaid
SC8566Medicare PIN