Healthcare Provider Details

I. General information

NPI: 1649525064
Provider Name (Legal Business Name): COASTAL CAROLINA NEONATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 JEFFERSON ST
WHITEVILLE NC
28472-3703
US

IV. Provider business mailing address

1915 GLEN MEADE RD
WILMINGTON NC
28403-6024
US

V. Phone/Fax

Practice location:
  • Phone: 910-772-9202
  • Fax: 910-772-9452
Mailing address:
  • Phone: 910-772-9202
  • Fax: 910-772-9452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FERNANDO MOYA
Title or Position: PRESIDENT
Credential: MD
Phone: 910-772-9202