1053614354 NPI number — OBSTETRIX MEDICAL GROUP OF COASTAL CAROLINA PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053614354 NPI number — OBSTETRIX MEDICAL GROUP OF COASTAL CAROLINA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OBSTETRIX MEDICAL GROUP OF COASTAL CAROLINA PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053614354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4991 LAKE BROOK DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
GLEN ALLEN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23060-9290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-627-4702
Provider Business Mailing Address Fax Number:
804-253-0408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2212 DELANEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28403-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-332-3660
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
POOLE
Authorized Official First Name:
ARNOLD
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
AUTHORIZED SIGNATOR
Authorized Official Telephone Number:
800-243-3839

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VM0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2026 www.npivalidator.com