Basic Information
Provider Information | |||||||||
NPI: | 1366498297 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COASTAL CAROLINA HEALTH CARE PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CCHC NEW BERN FAMILY PRACTICE & URGENT CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1040 MEDICAL PARK AVE | ||||||||
Address2: |   | ||||||||
City: | NEW BERN | ||||||||
State: | NC | ||||||||
PostalCode: | 285625248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2526331678 | ||||||||
FaxNumber: | 2526331403 | ||||||||
Practice Location | |||||||||
Address1: | 1040 MEDICAL PARK AVE | ||||||||
Address2: |   | ||||||||
City: | NEW BERN | ||||||||
State: | NC | ||||||||
PostalCode: | 285625248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2526331678 | ||||||||
FaxNumber: | 2526331403 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/25/2006 | ||||||||
LastUpdateDate: | 07/22/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NUCKOLLS | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2525146685 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
ID | Type | State | Issuer | Description | 790255H | 05 | NC |   | MEDICAID | 0255H | 01 | NC | BCBS OF NC | OTHER |