Provider Demographics
NPI:1740444967
Name:COASTAL CAROLINA MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:COASTAL CAROLINA MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:GROTELUSCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-784-8076
Mailing Address - Street 1:PO BOX 741261
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1261
Mailing Address - Country:US
Mailing Address - Phone:615-372-8500
Mailing Address - Fax:
Practice Address - Street 1:1000 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:HARDEEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29927-3446
Practice Address - Country:US
Practice Address - Phone:843-784-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL CAROLINA MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-16
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
42U101Medicare Oscar/Certification