Healthcare Provider Details

I. General information

NPI: 1053614354
Provider Name (Legal Business Name): OBSTETRIX MEDICAL GROUP OF COASTAL CAROLINA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2010
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2212 DELANEY AVE
WILMINGTON NC
28403-6011
US

IV. Provider business mailing address

4991 LAKE BROOK DR SUITE 300
GLEN ALLEN VA
23060-9290
US

V. Phone/Fax

Practice location:
  • Phone: 910-332-3660
  • Fax:
Mailing address:
  • Phone: 888-627-4702
  • Fax: 804-253-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ARNOLD M. POOLE
Title or Position: AUTHORIZED SIGNATOR
Credential:
Phone: 800-243-3839