=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326300781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COASTAL CAROLINA PHYSICIAN PRACTICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2012
-----------------------------------------------------
Last Update Date | 05/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 JACKSON AVE E
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29924-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-943-4003
-----------------------------------------------------
Fax | 803-943-4701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 408 JACKSON AVE E
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29924-3602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-943-4003
-----------------------------------------------------
Fax | 803-943-4701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL CFO, TENET
-----------------------------------------------------
Name | MR. WESLEY O. JAMES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-265-5009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------