Healthcare Provider Details

I. General information

NPI: 1417900556
Provider Name (Legal Business Name): COASTAL EMPIRE IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER DR
HARDEEVILLE SC
29927-3446
US

IV. Provider business mailing address

PO BOX 15479
SAVANNAH GA
31416-2179
US

V. Phone/Fax

Practice location:
  • Phone: 912-354-4164
  • Fax: 912-303-4940
Mailing address:
  • Phone: 912-354-4164
  • Fax: 912-303-4940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN C BRIDGES
Title or Position: PROVIDER RELATIONS
Credential:
Phone: 912-354-4164