MEDICARE: COAST KIDNEY DISEASE & INTERNAL MEDICINE

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	207RN0300X	Nephrology Physician	15918	MS

General Provider Information

NPI Number	:	1497847917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COAST KIDNEY DISEASE & INTERNAL MEDICINE

Provider Business Mailing Address
First Line	:	3099 BIENVILLE BLVD
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-4308
Country	:	US
Telephone Number	:	228-818-9008
Fax Number	:	228-818-0750

Provider Business Practice Location Address
First Line	:	3099 BIENVILLE BLVD
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-4308
Country	:	US
Telephone Number	:	228-818-9008
Fax Number	:	228-818-0750

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MISS ALANNA N BLACK
Credential	:
Telephone Number	:	228-818-9008

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	08/22/2020

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