Provider Demographics
NPI:1053580662
Name:COASTAL PHYSICAL MEDICINE, PA
Entity type:Organization
Organization Name:COASTAL PHYSICAL MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCSWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-762-2274
Mailing Address - Street 1:PO BOX 12819
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29422-2819
Mailing Address - Country:US
Mailing Address - Phone:843-762-2274
Mailing Address - Fax:843-762-2278
Practice Address - Street 1:3185 AZALEA DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8211
Practice Address - Country:US
Practice Address - Phone:843-762-2274
Practice Address - Fax:843-762-2278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19612261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2989Medicaid