Basic Information
| Provider Information | |||||||||
| NPI: | 1528623790 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL CAROLINA HEALTH CARE PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CCHC EXTENDED CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12248 | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285612248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525146685 | ||||||||
| FaxNumber: | 2525142745 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 MEDICAL PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285625248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526382273 | ||||||||
| FaxNumber: | 2526331403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2019 | ||||||||
| LastUpdateDate: | 01/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | NUCKOLLS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2525146685 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.