Provider Demographics
NPI:1326031485
Name:COASTAL CAROLINA FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:COASTAL CAROLINA FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ADM
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-426-5711
Mailing Address - Street 1:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:HERTFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27944-0650
Mailing Address - Country:US
Mailing Address - Phone:252-426-5711
Mailing Address - Fax:252-426-1999
Practice Address - Street 1:600 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:HERTFORD
Practice Address - State:NC
Practice Address - Zip Code:27944-1205
Practice Address - Country:US
Practice Address - Phone:252-426-5711
Practice Address - Fax:252-426-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0222LOtherBCBS
044647OtherTRIGON
NC890222LMedicaid
=========OtherTRICARE
NC2322485Medicare PIN