MEDICARE: COASTAL UROLOGICAL PARTNERS, 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	208800000X	Urology Physician

General Provider Information

NPI Number	:	1659451029
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL UROLOGICAL PARTNERS, LLC

Provider Business Mailing Address
First Line	:	11706 MERCY BLVD
Second Line	:	PLAZA A, SUITE 10
City	:	SAVANNAH
State	:	GA
Zip	:	31419-1751
Country	:	US
Telephone Number	:	912-920-0055
Fax Number	:	912-920-3367

Provider Business Practice Location Address
First Line	:	11706 MERCY BLVD
Second Line	:	PLAZA A, SUITE 10
City	:	SAVANNAH
State	:	GA
Zip	:	31419-1751
Country	:	US
Telephone Number	:	912-920-0055
Fax Number	:	912-920-3367

Authorized Official
Title or Position	:	BILLING/INSURANCE SUPERVISOR
Name	:	CAROL EVANS
Credential	:
Telephone Number	:	912-920-0055

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	08/22/2020

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