Healthcare Provider Details

I. General information

NPI: 1053580662
Provider Name (Legal Business Name): COASTAL PHYSICAL MEDICINE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3185 AZALEA DR
NORTH CHARLESTON SC
29405-8211
US

IV. Provider business mailing address

PO BOX 12819
CHARLESTON SC
29422-2819
US

V. Phone/Fax

Practice location:
  • Phone: 843-762-2274
  • Fax: 843-762-2278
Mailing address:
  • Phone: 843-762-2274
  • Fax: 843-762-2278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number19612
License Number StateSC

VIII. Authorized Official

Name: REBECCA MCSWAIN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 843-762-2274