Healthcare Provider Details

I. General information

NPI: 1881947802
Provider Name (Legal Business Name): SOUTHCOAST MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 US HIGHWAY 17
RICHMOND HILL GA
31324-3378
US

IV. Provider business mailing address

PO BOX 15849
SAVANNAH GA
31416-2549
US

V. Phone/Fax

Practice location:
  • Phone: 912-756-2292
  • Fax: 912-756-2289
Mailing address:
  • Phone: 912-303-3552
  • Fax: 912-303-3506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042084
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number039759
License Number StateGA

VIII. Authorized Official

Name: JOHN MARRERO
Title or Position: ADMINISTRATOR
Credential:
Phone: 912-303-3552