Provider Demographics
NPI:1275572794
Name:COASTAL CAROLINA HEALTH CARE
Entity Type:Organization
Organization Name:COASTAL CAROLINA HEALTH CARE
Other - Org Name:CCHC SOUTHERN GASTROENTEROLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:NUCKOLLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-514-6685
Mailing Address - Street 1:PO BOX 12248
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28561-2248
Mailing Address - Country:US
Mailing Address - Phone:252-634-9000
Mailing Address - Fax:252-634-9001
Practice Address - Street 1:3100 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:252-634-9000
Practice Address - Fax:252-634-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902309Medicaid
NC017HPOtherBCBS OF NC
NC2323301DMedicare PIN
NC5902309Medicaid