Provider Demographics
NPI:1669401964
Name:CAROLINA COAST PRIMARY MEDICINE
Entity type:Organization
Organization Name:CAROLINA COAST PRIMARY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BERTHA1
Authorized Official - Middle Name:TAYLOR-
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:910-296-1087
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:KENANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28349-0148
Mailing Address - Country:US
Mailing Address - Phone:910-296-1087
Mailing Address - Fax:910-296-1086
Practice Address - Street 1:275 N NC 24 & 50 HWY
Practice Address - Street 2:
Practice Address - City:KENANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28349-0148
Practice Address - Country:US
Practice Address - Phone:910-296-1087
Practice Address - Fax:910-296-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11515OtherBCBS
NC5900323Medicaid
NC=========OtherCIGNA
NC11515OtherBCBS
NC=========OtherUHC
NC5900323Medicaid
NC2347079Medicare ID - Type Unspecified