Basic Information
| Provider Information | |||||||||
| NPI: | 1598704009 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL CAROLINA HEALTH CARE PA | ||||||||
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| OtherOrganizationName: | CCHC HOSPITALISTS | ||||||||
| 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: | 2000 NEUSE BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285603449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525142061 | ||||||||
| FaxNumber: | 2525140371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 07/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | NUCKOLLS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2525146685 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 0285L | 01 | NC | BCBS OF NC | OTHER | 890285L | 05 | NC | MEDICAID |