Provider Demographics
NPI:1831252477
Name:COASTAL CAROLINA SURGICAL ASSOC
Entity type:Organization
Organization Name:COASTAL CAROLINA SURGICAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:MOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-524-8171
Mailing Address - Street 1:1055 RIBAUT ROAD
Mailing Address - Street 2:SUITE 30
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5447
Mailing Address - Country:US
Mailing Address - Phone:843-524-8171
Mailing Address - Fax:843-525-6613
Practice Address - Street 1:1055 RIBAUT ROAD
Practice Address - Street 2:SUITE 30
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5447
Practice Address - Country:US
Practice Address - Phone:843-524-8171
Practice Address - Fax:843-525-6613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty