1720014012 NPI number — COASTAL GASTROENTEROLOGY PLLC

Table of content: (NPI 1720014012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720014012 NPI number — COASTAL GASTROENTEROLOGY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL GASTROENTEROLOGY 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:
1720014012
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 MEDICAL CENTER DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUPPLY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-754-7790
Provider Business Mailing Address Fax Number:
910-754-7838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 MEDICAL CENTER DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUPPLY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-754-7790
Provider Business Practice Location Address Fax Number:
910-754-7838
Provider Enumeration Date:
06/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLT
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
LOVING
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
910-754-7790

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 891235G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1235G . This is a "BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com