MEDICARE: EAST COOPER PHYSICIAN GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1447021159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST COOPER PHYSICIAN GROUP LLC

Provider Business Mailing Address
First Line	:	PO BOX 604408
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-4408
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 SALTERBECK ST STE 100A
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29466-7118
Country	:	US
Telephone Number	:	843-606-9474
Fax Number	:	843-606-9482

Authorized Official
Title or Position	:	RCS MANAGER
Name	:	DOREATHA ROGERS
Credential	:
Telephone Number	:	980-302-7992

Provider Enumeration Date	:	01/11/2024
Last Update Date	:	02/28/2026

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