Healthcare Provider Details

I. General information

NPI: 1497717086
Provider Name (Legal Business Name): COASTAL CAROLINA OTOLARYNGOLOGY ASSOCIATES,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 08/26/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3822 MAYFAIR ST
MYRTLE BEACH SC
29577-0912
US

IV. Provider business mailing address

3822 MAYFAIR ST
MYRTLE BEACH SC
29577-0912
US

V. Phone/Fax

Practice location:
  • Phone: 843-449-6449
  • Fax: 843-449-1069
Mailing address:
  • Phone: 843-449-6449
  • Fax: 843-449-1069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL L ROSNER
Title or Position: VICE PRESIDENT
Credential: MD
Phone: 843-449-6449