Healthcare Provider Details

I. General information

NPI: 1750142246
Provider Name (Legal Business Name): EAST COOPER PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 N HIGHWAY 17
MT PLEASANT SC
29466-9123
US

IV. Provider business mailing address

PO BOX 37642
BELFAST ME
04915-1218
US

V. Phone/Fax

Practice location:
  • Phone: 843-884-5200
  • Fax: 843-884-6417
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DOREATHA ROGERS
Title or Position: RCS MANAGER
Credential:
Phone: 980-302-7992