Provider Demographics
NPI:1487761318
Name:COASTAL CAROLINA PHYSICIAN PRACTICES LLC
Entity type:Organization
Organization Name:COASTAL CAROLINA PHYSICIAN PRACTICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-836-3667
Mailing Address - Street 1:PO BOX 1109
Mailing Address - Street 2:
Mailing Address - City:HARDEEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29927-1109
Mailing Address - Country:US
Mailing Address - Phone:843-836-3667
Mailing Address - Fax:843-836-3677
Practice Address - Street 1:29 PLANTATION PARK DR
Practice Address - Street 2:SUITE 204
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-9001
Practice Address - Country:US
Practice Address - Phone:843-836-3667
Practice Address - Fax:843-836-3677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4679Medicaid
SC8640Medicare PIN