Provider Demographics
NPI:1750567970
Name:COASTAL CAROLINA HEALTH CARE PA
Entity type:Organization
Organization Name:COASTAL CAROLINA HEALTH CARE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:NUCKOLLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-514-6685
Mailing Address - Street 1:PO BOX 12248
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28561-2248
Mailing Address - Country:US
Mailing Address - Phone:252-514-6685
Mailing Address - Fax:252-514-2745
Practice Address - Street 1:1020 MEDICAL PARK AVENUE
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5248
Practice Address - Country:US
Practice Address - Phone:252-514-6685
Practice Address - Fax:252-514-2745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909118Medicaid
NCCE8273Medicare PIN
NC2323301DMedicare PIN