Healthcare Provider Details

I. General information

NPI: 1528623790
Provider Name (Legal Business Name): COASTAL CAROLINA HEALTH CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 MEDICAL PARK AVE
NEW BERN NC
28562-5248
US

IV. Provider business mailing address

PO BOX 12248
NEW BERN NC
28561-2248
US

V. Phone/Fax

Practice location:
  • Phone: 252-638-2273
  • Fax: 252-633-1403
Mailing address:
  • Phone: 252-514-6685
  • Fax: 252-514-2745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN W. NUCKOLLS
Title or Position: CEO
Credential:
Phone: 252-514-6685