Basic Information
| Provider Information | |||||||||
| NPI: | 1144462631 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL CAROLINA NEONATOLOGY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2131 S 17TH ST | ||||||||
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| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107729202 | ||||||||
| FaxNumber: | 9107729452 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 S 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107729202 | ||||||||
| FaxNumber: | 9107729452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2009 | ||||||||
| LastUpdateDate: | 10/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | MOYA | ||||||||
| AuthorizedOfficialFirstName: | FERNANDO | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | INCORPORATOR | ||||||||
| AuthorizedOfficialTelephone: | 9107729202 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No ID Information.