Basic Information
| Provider Information | |||||||||
| NPI: | 1780623207 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL CAROLINA HEALTH CARE PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CCHC NEW BERN INTERNAL MEDICINE SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 NEWMAN RD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285625238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526335333 | ||||||||
| FaxNumber: | 2526339443 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 NEWMAN RD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285625238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526335333 | ||||||||
| FaxNumber: | 2526339443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 07/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | NUCKOLLS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2525146685 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 890255L | 05 | NC | MEDICAID | 0255L | 01 | NC | BCBS OF NC | OTHER |