1578656773 NPI number — COASTAL VASCULAR INSTITUTE, PA

Table of content: (NPI 1578656773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578656773 NPI number — COASTAL VASCULAR INSTITUTE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL VASCULAR INSTITUTE, PA
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:
COASTAL CAROLINA SURGICAL ASSOCIATES, PA
Provider Other Organization Name Type Code:
4
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:
1578656773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1411 PHYSICIANS DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28401-7338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-343-0811
Provider Business Mailing Address Fax Number:
910-343-5719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1411 PHYSICIANS DRIVE
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:
28401-7338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-343-0811
Provider Business Practice Location Address Fax Number:
910-343-5719
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARCUSSEN
Authorized Official First Name:
KARA
Authorized Official Middle Name:
FLORENCE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
910-343-0811

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  CERTIFICATE # 40958 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 40958 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0129X , with the licence number: CERTIFICATE # 40958 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2086S0129X , with the licence number: 40958 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 79-0271C , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 142384 . This is a "GRP UNITED HEALTHCARE #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0271C . This is a "BCBS OF NC GROUP #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0271C . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: CB0557 . This is a "RAILROAD MEDICARE GROUP #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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