MEDICARE: COASTAL FAMILY MEDICINE

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	173000000X	Legal Medicine	MD 7055	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2958	OTHER	SC	MEDICARE PROVIDER NUMBER

Other Identifiers

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

General Provider Information

NPI Number	:	1548459597
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL FAMILY MEDICINE

Provider Business Mailing Address
First Line	:	8014 MYRTLE TRACE DR
Second Line	:
City	:	CONWAY
State	:	SC
Zip	:	29526-8945
Country	:	US
Telephone Number	:	843-347-7224
Fax Number	:	843-347-7335

Provider Business Practice Location Address
First Line	:	8014 MYRTLE TRACE DR
Second Line	:
City	:	CONWAY
State	:	SC
Zip	:	29526-8945
Country	:	US
Telephone Number	:	843-347-7224
Fax Number	:	843-347-7335

Authorized Official
Title or Position	:	OWNER
Name	:	JONATHAN L DIETER JR.
Credential	:	MD
Telephone Number	:	843-347-7224

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	10/17/2007

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Directions to “COASTAL FAMILY MEDICINE ” Practice Location

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