Provider Demographics
NPI:1124307509
Name:COASTAL CAROLINA MEDICAL CENTER, INC
Entity type:Organization
Organization Name:COASTAL CAROLINA MEDICAL CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:GROTELUSCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-784-8076
Mailing Address - Street 1:PO BOX 741261
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1261
Mailing Address - Country:US
Mailing Address - Phone:843-784-3101
Mailing Address - Fax:843-784-5313
Practice Address - Street 1:10911 N JACOB SMART BLVD
Practice Address - Street 2:D
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-2729
Practice Address - Country:US
Practice Address - Phone:843-784-3101
Practice Address - Fax:843-784-5313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health