Basic Information
| Provider Information | |||||||||
| NPI: | 1144270307 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL RADIOLOGY ASSOCIATES, PLLC | ||||||||
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| OtherOrganizationName: | COASTAL RADIOLOGY ASSOCIATES PLLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 686 | ||||||||
| Address2: | |||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544020686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8334170599 | ||||||||
| FaxNumber: | 2526330084 | ||||||||
| Practice Location | |||||||||
| Address1: | 722 NEWMAN RD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285625238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885928646 | ||||||||
| FaxNumber: | 2526330084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | CASSIN | ||||||||
| AuthorizedOfficialFirstName: | NAOMI | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3127248477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02851 | 01 | NC | BCBS OF NC | OTHER | 153000500 | 01 | NC | DOL | OTHER | 8902851 | 05 | NC | MEDICAID | 760158 | 01 | NC | MAMSI | OTHER |