Healthcare Provider Details

I. General information

NPI: 1770700759
Provider Name (Legal Business Name): COASTAL PEDIATRIC ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2067 CHARLIE HALL BLVD
CHARLESTON SC
29414-5834
US

IV. Provider business mailing address

4975 LACROSS RD STE 150
NORTH CHARLESTON SC
29406-6531
US

V. Phone/Fax

Practice location:
  • Phone: 843-573-2535
  • Fax: 843-573-2534
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT ANDREW CLIFFORD
Title or Position: PARTNER
Credential: M.D.
Phone: 843-573-2535