Provider Demographics
NPI:1245402064
Name:COASTAL CAROLINA HEART LLC
Entity Type:Organization
Organization Name:COASTAL CAROLINA HEART LLC
Other - Org Name:WILMINGTON HEART CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUIDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-708-6610
Mailing Address - Street 1:10720 SIKES PL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-8141
Mailing Address - Country:US
Mailing Address - Phone:704-708-6610
Mailing Address - Fax:888-401-6931
Practice Address - Street 1:1604 PHYSICIANS DR
Practice Address - Street 2:SUITE 104
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7362
Practice Address - Country:US
Practice Address - Phone:910-762-2292
Practice Address - Fax:910-762-2208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016N9OtherBLUE CROSS BLUE SHIELD NC