Provider Demographics
NPI:1023157575
Name:COASTAL VASCULAR & VEIN CENTER PA
Entity type:Organization
Organization Name:COASTAL VASCULAR & VEIN CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CODER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLUM
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:843-300-3588
Mailing Address - Street 1:1327 ASHLEY RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5384
Mailing Address - Country:US
Mailing Address - Phone:843-577-4551
Mailing Address - Fax:843-577-2227
Practice Address - Street 1:1327 ASHLEY RIVER RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5384
Practice Address - Country:US
Practice Address - Phone:843-577-4551
Practice Address - Fax:843-577-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
SC2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC610303400OtherU S DEPARTMENT OF LABOR
SC0489056OtherAETNA
SCPA1729Medicaid
SCPA1729Medicaid
SC610303400OtherU S DEPARTMENT OF LABOR