Basic Information
| Provider Information | |||||||||
| NPI: | 1538316575 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL CAROLINA MEDICAL CENTER INC | ||||||||
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| OtherOrganizationName: | COASTAL CAROLINA MEDICAL CENTER-ED PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194342 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 MEDICAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | HARDEEVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437848000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2008 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | GROTELUSCHEN | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8437848076 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GP4209 | 05 | SC | MEDICAID |