Basic Information
| Provider Information | |||||||||
| NPI: | 1861446346 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COASTAL CAROLINA HEALTH CARE PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CCHC ATLANTIC INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12248 | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285612248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526349090 | ||||||||
| FaxNumber: | 2526349915 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 NEWMAN RD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285625238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526349090 | ||||||||
| FaxNumber: | 2526349915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | NUCKOLLS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2525146685 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 015UR | 01 | NC | BCBS OF NORTH CAROLINA | OTHER | 89015UR | 05 | NC | MEDICAID |