Healthcare Provider Details

I. General information

NPI: 1679554752
Provider Name (Legal Business Name): COASTAL CAROLINA NEPHROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date: 03/03/2006
Reactivation Date: 08/29/2007

III. Provider practice location address

1938-A CHARLIE HALL BLVD
CHARLESTON SC
29414-5837
US

IV. Provider business mailing address

1938-A CHARLIE HALL BLVD
CHARLESTON SC
29414-5837
US

V. Phone/Fax

Practice location:
  • Phone: 843-554-9313
  • Fax: 843-744-5961
Mailing address:
  • Phone: 843-554-9313
  • Fax: 843-744-5961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA R STEWART
Title or Position: PARTNER
Credential: MD
Phone: 843-554-9313