Provider Demographics
NPI:1144526500
Name:COASTAL CAROLINA MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:COASTAL CAROLINA MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:O
Authorized Official - Last Name:GROTELUSCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-784-8076
Mailing Address - Street 1:PO BOX 741261
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1261
Mailing Address - Country:US
Mailing Address - Phone:843-784-8293
Mailing Address - Fax:843-784-7801
Practice Address - Street 1:1010 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 240
Practice Address - City:HARDEEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29927-3447
Practice Address - Country:US
Practice Address - Phone:843-784-8293
Practice Address - Fax:843-784-7801
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL CAROLINA HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-02
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC 551Medicaid
SC423444Medicare Oscar/Certification