1639336027 NPI number — COASTAL CAROLINA FOOT & ANKLE ASSOCIATION PA

Table of content: (NPI 1639336027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639336027 NPI number — COASTAL CAROLINA FOOT & ANKLE ASSOCIATION PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL CAROLINA FOOT & ANKLE ASSOCIATION 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:
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:
1639336027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 N NORWOOD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLACE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28466-2730
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-285-3362
Provider Business Mailing Address Fax Number:
910-285-6683

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 N NORWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLACE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28466-2730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-285-3362
Provider Business Practice Location Address Fax Number:
910-285-6683
Provider Enumeration Date:
05/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
910-343-8889

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  230 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0131X , with the licence number: 449 , 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: 890152P , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DR7169 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: B1114 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 2347992 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0152P . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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