Provider Demographics
NPI:1740345149
Name:COASTAL SURGICAL SPECIALISTS, PC
Entity type:Organization
Organization Name:COASTAL SURGICAL SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BASIL
Authorized Official - Middle Name:S
Authorized Official - Last Name:SKENDERIS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:757-481-4424
Mailing Address - Street 1:1120 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2418
Mailing Address - Country:US
Mailing Address - Phone:757-481-4424
Mailing Address - Fax:757-481-3820
Practice Address - Street 1:1120 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2418
Practice Address - Country:US
Practice Address - Phone:757-481-4424
Practice Address - Fax:757-481-3820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA300012OtherOPTIMA VENDER #
VA5975074OtherAETNA
NC89013HRMedicaid
VA5975074OtherAETNA
NC89013HRMedicaid