Provider Demographics
NPI:1265898191
Name:COASTAL CAROLINA INFECTIOUS DISEASE, LLC
Entity type:Organization
Organization Name:COASTAL CAROLINA INFECTIOUS DISEASE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-668-2376
Mailing Address - Street 1:1110 LONDON ST STE 102
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5799
Mailing Address - Country:US
Mailing Address - Phone:843-668-2376
Mailing Address - Fax:843-748-0613
Practice Address - Street 1:1110 LONDON ST STE 102
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577
Practice Address - Country:US
Practice Address - Phone:843-668-2376
Practice Address - Fax:843-748-0613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty