Provider Demographics
NPI:1528101664
Name:COASTAL CAROLINA UROLOGY GROUP, LLC
Entity type:Organization
Organization Name:COASTAL CAROLINA UROLOGY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:HOWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-482-4871
Mailing Address - Street 1:PO BOX 440007
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37244-0007
Mailing Address - Country:US
Mailing Address - Phone:888-482-4871
Mailing Address - Fax:615-261-6052
Practice Address - Street 1:1055 RIBAUT RD
Practice Address - Street 2:SUITE 10
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5423
Practice Address - Country:US
Practice Address - Phone:843-524-7607
Practice Address - Fax:843-524-6737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC200011208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCG7000OtherRR MEDICARE
SCCG7000OtherRR MEDICARE