Healthcare Provider Details

I. General information

NPI: 1265966337
Provider Name (Legal Business Name): COASTAL INTERNAL MEDICINE & GERIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2017
Last Update Date: 04/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

597 OLD MOUNT HOLLY RD STE 202
GOOSE CREEK SC
29445-2831
US

IV. Provider business mailing address

597 OLD MOUNT HOLLY RD STE 202
GOOSE CREEK SC
29445-2831
US

V. Phone/Fax

Practice location:
  • Phone: 843-466-8000
  • Fax:
Mailing address:
  • Phone: 843-466-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number33988
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number33988
License Number StateSC

VIII. Authorized Official

Name: MADHAVI AKKINENI
Title or Position: OWNER
Credential: M.D.
Phone: 843-466-8000