Healthcare Provider Details

I. General information

NPI: 1215242755
Provider Name (Legal Business Name): COASTAL PLASTIC SURGERY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 FIRST COLONIAL RD SUITE 100
VIRGINIA BEACH VA
23454-2274
US

IV. Provider business mailing address

1200 FIRST COLONIAL RD SUITE 100
VIRGINIA BEACH VA
23454-2274
US

V. Phone/Fax

Practice location:
  • Phone: 757-481-7788
  • Fax: 757-481-1707
Mailing address:
  • Phone: 757-481-7788
  • Fax: 757-481-1707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number0101025726
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number0101025726
License Number StateVA

VIII. Authorized Official

Name: DR. GLENN R. CARWELL JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 757-481-7788