Healthcare Provider Details

I. General information

NPI: 1932584885
Provider Name (Legal Business Name): COASTAL PODIATRY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3997 MEETING ST
LORIS SC
29569-3053
US

IV. Provider business mailing address

8141 ROURK ST
MYRTLE BEACH SC
29572-4128
US

V. Phone/Fax

Practice location:
  • Phone: 843-449-8079
  • Fax: 843-497-6147
Mailing address:
  • Phone: 843-449-8079
  • Fax: 843-497-6147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateSC

VIII. Authorized Official

Name: SUSAN E FISHER
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 843-449-8079