Healthcare Provider Details

I. General information

NPI: 1467451922
Provider Name (Legal Business Name): SOUTHCOAST MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BENEFIELD DR
SAVANNAH GA
31406-2604
US

IV. Provider business mailing address

PO BOX 15849
SAVANNAH GA
31416-2549
US

V. Phone/Fax

Practice location:
  • Phone: 912-303-3552
  • Fax: 912-303-3506
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 Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number047425
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number022482
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateGA
# 9
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateGA
# 10
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number064752
License Number StateGA
# 11
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateGA
# 12
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number021614
License Number StateGA
# 13
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateGA
# 14
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateGA
# 15
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateGA

VIII. Authorized Official

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