Provider Demographics
NPI:1033157615
Name:COASTAL EAR NOSE & THROAT ASSOCIATES PLLC
Entity Type:Organization
Organization Name:COASTAL EAR NOSE & THROAT ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-638-2515
Mailing Address - Street 1:3110 WELLONS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5247
Mailing Address - Country:US
Mailing Address - Phone:252-638-2515
Mailing Address - Fax:252-638-8538
Practice Address - Street 1:3110 WELLONS BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5247
Practice Address - Country:US
Practice Address - Phone:252-638-2515
Practice Address - Fax:252-638-8538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891170NMedicaid
NC8936530Medicaid
NC891157JMedicaid
NC8953662Medicaid
206731DMedicare ID - Type Unspecified
C88101Medicare UPIN
NC8936530Medicaid
NC891157JMedicaid
NC891170NMedicaid
2279606DMedicare ID - Type Unspecified
208412DMedicare ID - Type Unspecified
NC8953662Medicaid
NC2349967Medicare PIN