MEDICARE: COASTAL ONCOLOGY & HEMATOLOGY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RH0003X	Hematology & Oncology Physician	9601134	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0285R	OTHER	NC	BLUE CROSS BLUE SHIELD #

General Provider Information

NPI Number	:	1912077090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COASTAL ONCOLOGY & HEMATOLOGY PA

Provider Business Mailing Address
First Line	:	3322 WELLONS BLVD
Second Line	:
City	:	NEW BERN
State	:	NC
Zip	:	28562-5290
Country	:	US
Telephone Number	:	252-634-1616
Fax Number	:	252-634-1617

Provider Business Practice Location Address
First Line	:	3322 WELLONS BLVD
Second Line	:
City	:	NEW BERN
State	:	NC
Zip	:	28562-5290
Country	:	US
Telephone Number	:	252-634-1616
Fax Number	:	252-634-1617

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANNA G FAIDAS
Credential	:	MD
Telephone Number	:	252-634-1616

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	08/22/2020

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