Provider Demographics
NPI:1306029004
Name:COASTAL CAROLINA RADIOLOGY, PLLC
Entity Type:Organization
Organization Name:COASTAL CAROLINA RADIOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JEFFERSON
Authorized Official - Last Name:BEAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-384-4615
Mailing Address - Street 1:PO BOX 12017
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23612-2017
Mailing Address - Country:US
Mailing Address - Phone:757-867-6101
Mailing Address - Fax:757-867-6588
Practice Address - Street 1:1144 N ROAD ST
Practice Address - Street 2:HWY 17N
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3353
Practice Address - Country:US
Practice Address - Phone:252-384-4615
Practice Address - Fax:252-384-4684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908639Medicaid
NC019YNOtherBCBS
NCDG9218Medicare PIN
NC5908639Medicaid