Provider Demographics
NPI:1811681018
Name:COASTAL WOUND CARE, LLC
Entity type:Organization
Organization Name:COASTAL WOUND CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES DURKAN
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-368-7864
Mailing Address - Street 1:2060 CHARLIE HALL BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-6066
Mailing Address - Country:US
Mailing Address - Phone:843-483-0193
Mailing Address - Fax:839-213-4599
Practice Address - Street 1:2060 CHARLIE HALL BLVD STE A
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-6066
Practice Address - Country:US
Practice Address - Phone:843-483-0193
Practice Address - Fax:839-213-4599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-08
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC331297Medicaid