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Organization
COASTAL FAMILY MEDICINE
Active
Organization
COASTAL FAMILY MEDICINE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JONATHAN L DIETER JR. MD (OWNER)
(843) 347-7224
Entity
Organization
Contact information
Practice address
8014 MYRTLE TRACE DR, CONWAY, SC 29526-8945
(843) 347-7224
(843) 347-7335
Mailing address
8014 MYRTLE TRACE DR, CONWAY, SC 29526-8945
(843) 347-7224
(843) 347-7335
Taxonomy
Speciality
Code
Description
License number
State
173000000X
Legal Medicine
Primary
MD 7055
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2958
MEDICARE PROVIDER NUMBER
SC
01
—
PC4269
MEDICAID PROVIDER NUMBER
SC
Enumeration date
10/16/2007
Last updated
10/17/2007
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