Provider Demographics
NPI:1053415737
Name:COASTAL CAROLINA FAMILY MEDICINE
Entity type:Organization
Organization Name:COASTAL CAROLINA FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:HUTCHINGS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:843-784-8300
Mailing Address - Street 1:PO BOX 1633
Mailing Address - Street 2:
Mailing Address - City:HARDEEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29927-1633
Mailing Address - Country:US
Mailing Address - Phone:843-784-8300
Mailing Address - Fax:843-784-8304
Practice Address - Street 1:1010 MEDICAL CENTER DR STE 240
Practice Address - Street 2:
Practice Address - City:HARDEEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29927-3448
Practice Address - Country:US
Practice Address - Phone:843-784-8300
Practice Address - Fax:843-784-8304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC842207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3984Medicaid