MEDICARE: COASTAL RHEUMATOLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RR0500X	Rheumatology Physician		GA

General Provider Information

NPI Number	:	1417368853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL RHEUMATOLOGY, LLC

Provider Business Mailing Address
First Line	:	4849 PAULSEN ST
Second Line	:	SUITE 312
City	:	SAVANNAH
State	:	GA
Zip	:	31405-4423
Country	:	US
Telephone Number	:	912-349-4227
Fax Number	:

Provider Business Practice Location Address
First Line	:	4849 PAULSEN ST
Second Line	:	SUITE 312
City	:	SAVANNAH
State	:	GA
Zip	:	31405-4423
Country	:	US
Telephone Number	:	912-349-4227
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHARLES FREDERICK DEGENHARDT III
Credential	:	MD
Telephone Number	:	912-349-4227

Provider Enumeration Date	:	05/19/2014
Last Update Date	:	02/06/2017

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