Healthcare Provider Details

I. General information

NPI: 1659451029
Provider Name (Legal Business Name): COASTAL UROLOGICAL PARTNERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11706 MERCY BLVD PLAZA A, SUITE 10
SAVANNAH GA
31419-1751
US

IV. Provider business mailing address

11706 MERCY BLVD PLAZA A, SUITE 10
SAVANNAH GA
31419-1751
US

V. Phone/Fax

Practice location:
  • Phone: 912-920-0055
  • Fax: 912-920-3367
Mailing address:
  • Phone: 912-920-0055
  • Fax: 912-920-3367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: CAROL EVANS
Title or Position: BILLING/INSURANCE SUPERVISOR
Credential:
Phone: 912-920-0055