Provider Demographics
NPI:1104905405
Name:SOUTHERN COASTAL ENT PC
Entity type:Organization
Organization Name:SOUTHERN COASTAL ENT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERMAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-265-3210
Mailing Address - Street 1:2500 STARLING ST
Mailing Address - Street 2:SUITE 403
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4265
Mailing Address - Country:US
Mailing Address - Phone:912-265-3210
Mailing Address - Fax:912-265-1481
Practice Address - Street 1:2500 STARLING ST
Practice Address - Street 2:SUITE 403
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4265
Practice Address - Country:US
Practice Address - Phone:912-265-3210
Practice Address - Fax:912-265-1481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057327207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA078903405AMedicaid
GA511G700181Medicare PIN
GA078903405AMedicaid