MEDICARE: COASTAL CAROLINA OTOLARYNGOLOGY ASSOCIATES,PA

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	207Y00000X	Otolaryngology Physician
2	207YX0007X	Plastic Surgery within the Head & Neck (Otolaryngology) Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497717086
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL CAROLINA OTOLARYNGOLOGY ASSOCIATES,PA

Provider Business Mailing Address
First Line	:	3822 MAYFAIR ST
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-0912
Country	:	US
Telephone Number	:	843-449-6449
Fax Number	:	843-449-1069

Provider Business Practice Location Address
First Line	:	3822 MAYFAIR ST
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-0912
Country	:	US
Telephone Number	:	843-449-6449
Fax Number	:	843-449-1069

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. DANIEL L ROSNER
Credential	:	MD
Telephone Number	:	843-449-6449

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	08/26/2025

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