Basic Information
| Provider Information | |||||||||
| NPI: | 1518179852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 313 WALNUT ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284014067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102542022 | ||||||||
| FaxNumber: | 9103434227 | ||||||||
| Practice Location | |||||||||
| Address1: | 313 WALNUT ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284014067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102542022 | ||||||||
| FaxNumber: | 9103434227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 02/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0015X | 29062 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychosomatic Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5918323 | 05 | NC | MEDICAID |