Provider Demographics
NPI:1164702551
Name:COASTAL PRIMARY HEALTH SPECIALISTS PLLC
Entity Type:Organization
Organization Name:COASTAL PRIMARY HEALTH SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PAMMELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:910-259-3489
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-1550
Mailing Address - Country:US
Mailing Address - Phone:910-259-3489
Mailing Address - Fax:
Practice Address - Street 1:407 EAST FREMONT STREET
Practice Address - Street 2:
Practice Address - City:BURGAW
Practice Address - State:NC
Practice Address - Zip Code:28425-4104
Practice Address - Country:US
Practice Address - Phone:910-259-3489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA541Medicare PIN