Provider Demographics
NPI:1497724991
Name:COASTAL CAROLINA PATHOLOGY, PA
Entity Type:Organization
Organization Name:COASTAL CAROLINA PATHOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-395-4441
Mailing Address - Street 1:2606 IRON GATE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2494
Mailing Address - Country:US
Mailing Address - Phone:910-395-4441
Mailing Address - Fax:910-395-7074
Practice Address - Street 1:2606 IRON GATE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2573
Practice Address - Country:US
Practice Address - Phone:910-395-4441
Practice Address - Fax:910-395-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
690009530OtherRAILROAD MEDICARE
NC7001210Medicaid
NC014KUOtherBCBS
2552669Medicare PIN