Provider Demographics
NPI:1063432391
Name:COASTAL CANCER CENTER LLC
Entity type:Organization
Organization Name:COASTAL CANCER CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-692-5000
Mailing Address - Street 1:8121 ROURK ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4128
Mailing Address - Country:US
Mailing Address - Phone:843-692-5000
Mailing Address - Fax:843-692-5015
Practice Address - Street 1:817 FARRAR DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8747
Practice Address - Country:US
Practice Address - Phone:843-234-1660
Practice Address - Fax:843-692-5015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
SC11181207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790248NMedicaid
SCGP2750Medicaid
NC790248NMedicaid
SCGP2750Medicaid