Provider Demographics
NPI:1578656773
Name:COASTAL VASCULAR INSTITUTE, PA
Entity Type:Organization
Organization Name:COASTAL VASCULAR INSTITUTE, PA
Other - Org Name:COASTAL CAROLINA SURGICAL ASSOCIATES, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KARA
Authorized Official - Middle Name:FLORENCE
Authorized Official - Last Name:MARCUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-343-0811
Mailing Address - Street 1:1411 PHYSICIANS DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7338
Mailing Address - Country:US
Mailing Address - Phone:910-343-0811
Mailing Address - Fax:910-343-5719
Practice Address - Street 1:1411 PHYSICIANS DRIVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7338
Practice Address - Country:US
Practice Address - Phone:910-343-0811
Practice Address - Fax:910-343-5719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCERTIFICATE # 40958208600000X, 2086S0129X
NC40958208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC79-0271CMedicaid
NC142384OtherGRP UNITED HEALTHCARE #
NC0271COtherBCBS OF NC GROUP #
NC0271COtherBCBS OF NC
NCCB0557OtherRAILROAD MEDICARE GROUP #
230815Medicare PIN