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General NPI Number Information
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NPI Number | 1861745119
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Entity Type | Organization
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Legal Business Name | SOUTHCOAST MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 10/24/2012
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Last Update Date | 10/24/2012
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Provider Practice Location Address
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Address Line | 1326 EISENHOWER DR
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City | SAVANNAH
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State | GA
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Zip | 31406-3928
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Country | US
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Telephone | 912-691-4100
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Fax | 912-691-4209
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Provider Business Mailing Address
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Address Line | PO BOX 15849
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City | SAVANNAH
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State | GA
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Zip | 31416-2549
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Country | US
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Telephone | 912-303-3552
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Fax | 912-303-3506
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JOHN MARRERO
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Credential |
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Telephone | 912-303-3552
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 020999
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 038715
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 026247
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 064752
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License Number State | GA
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Taxonomy #5
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 039937
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License Number State | GA
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Taxonomy #6
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5306
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License Number State | GA
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Taxonomy #7
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | RN077768
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License Number State | GA
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Taxonomy #8
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 047425
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License Number State | GA
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