Provider Demographics
NPI:1619903176
Name:DERMATOLOGY ASSOCIATES OF COASTAL CAROLINA, PA
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF COASTAL CAROLINA, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:POLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-633-4461
Mailing Address - Street 1:PO BOX 890283
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0283
Mailing Address - Country:US
Mailing Address - Phone:252-633-4461
Mailing Address - Fax:252-633-6016
Practice Address - Street 1:2115 NEUSE BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-4309
Practice Address - Country:US
Practice Address - Phone:252-633-4461
Practice Address - Fax:252-633-6016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDF3377OtherRR MEDICARE
NC017RMOtherBCBS GROUP PROVIDER NUMBE
NCDF3377OtherRR MEDICARE