Provider Demographics
NPI:1013131820
Name:COASTAL NEUROLOGY ASSOCIATES
Entity Type:Organization
Organization Name:COASTAL NEUROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALED
Authorized Official - Middle Name:
Authorized Official - Last Name:JREISAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-633-3744
Mailing Address - Street 1:729 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28560-4547
Mailing Address - Country:US
Mailing Address - Phone:252-633-3744
Mailing Address - Fax:
Practice Address - Street 1:729 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-4547
Practice Address - Country:US
Practice Address - Phone:252-633-3744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912867Medicaid
NC01344OtherBLUE CROSS GROUP NUMBER
NC12867OtherBALLANGER INDIVIDUAL #
NC45782OtherJREISAT BCBS INDIVIDUAL
NC8901344Medicaid
NC8945782Medicaid
NC230248Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
NC8945782Medicaid
NC8901344Medicaid
NC45782OtherJREISAT BCBS INDIVIDUAL
NCC84802Medicare UPIN