Provider Demographics
NPI:1720128044
Name:COASTAL CAROLINA ANESTHESIOLOGIST, P.A.
Entity Type:Organization
Organization Name:COASTAL CAROLINA ANESTHESIOLOGIST, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:ZAKI
Authorized Official - Last Name:DIMITRIOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-642-6427
Mailing Address - Street 1:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-0505
Mailing Address - Country:US
Mailing Address - Phone:910-642-6427
Mailing Address - Fax:910-642-5769
Practice Address - Street 1:500 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3634
Practice Address - Country:US
Practice Address - Phone:910-642-6427
Practice Address - Fax:910-642-5769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC015KMOtherBC AND BS OF NC
NC89015KMMedicaid
NCF65096Medicare UPIN
NC89015KMMedicaid
NCB70944Medicare UPIN
NC2335674Medicare ID - Type UnspecifiedGROUP PROVIDER ID#