Healthcare Provider Details

I. General information

NPI: 1154822971
Provider Name (Legal Business Name): COASTAL EAR, NOSE & THROAT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 02/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BLUE MOON XING STE 103
POOLER GA
31322-9698
US

IV. Provider business mailing address

322 COMMERCIAL DR
SAVANNAH GA
31406-3625
US

V. Phone/Fax

Practice location:
  • Phone: 912-450-2336
  • Fax:
Mailing address:
  • Phone: 912-355-2335
  • Fax: 770-217-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number38323
License Number StateGA

VIII. Authorized Official

Name: DAVID S OLIVER
Title or Position: CEO
Credential: MD
Phone: 912-355-2335