Healthcare Provider Details

I. General information

NPI: 1982820031
Provider Name (Legal Business Name): COASTAL DERMATOLOGY & SURGERY CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 03/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 DELANEY AVENUE
WILMINGTON NC
28403-6002
US

IV. Provider business mailing address

2504 DELANEY AVE
WILMINGTON NC
28403-6002
US

V. Phone/Fax

Practice location:
  • Phone: 910-343-0626
  • Fax: 910-343-8012
Mailing address:
  • Phone: 910-343-0626
  • Fax: 910-343-8012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number200000526
License Number StateNC

VIII. Authorized Official

Name: HEATHER A LOESCH
Title or Position: OWNER PRESIDENT
Credential: MD
Phone: 910-343-0626