Provider Demographics
NPI:1740584770
Name:SOUTHCOAST MEDICAL GROUP P C
Entity type:Organization
Organization Name:SOUTHCOAST MEDICAL GROUP P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARRERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-303-3552
Mailing Address - Street 1:PO BOX 16029
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-2729
Mailing Address - Country:US
Mailing Address - Phone:912-691-4100
Mailing Address - Fax:912-691-4289
Practice Address - Street 1:1326 EISENHOWER DR BLDG 1
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3928
Practice Address - Country:US
Practice Address - Phone:912-691-3528
Practice Address - Fax:912-691-3517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0097203336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128560OtherPK
GA3000032057AMedicaid