Provider Demographics
NPI:1982820031
Name:COASTAL DERMATOLOGY & SURGERY CENTER, PA
Entity Type:Organization
Organization Name:COASTAL DERMATOLOGY & SURGERY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOESCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-343-0626
Mailing Address - Street 1:2504 DELANEY AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6002
Mailing Address - Country:US
Mailing Address - Phone:910-343-0626
Mailing Address - Fax:910-343-8012
Practice Address - Street 1:2504 DELANEY AVENUE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6002
Practice Address - Country:US
Practice Address - Phone:910-343-0626
Practice Address - Fax:910-343-8012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000526174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126ACMedicaid
NC89126ACMedicaid
NC2320973Medicare ID - Type Unspecified