Basic Information
| Provider Information | |||||||||
| NPI: | 1649525064 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COASTAL CAROLINA NEONATOLOGY, PLLC | ||||||||
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| OtherOrganizationName: | CCN-WHITEVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1915 GLEN MEADE RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107729202 | ||||||||
| FaxNumber: | 9107729452 | ||||||||
| Practice Location | |||||||||
| Address1: | 823 JEFFERSON ST | ||||||||
| Address2: | |||||||||
| City: | WHITEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284723703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107729202 | ||||||||
| FaxNumber: | 9107729452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2012 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | MOYA | ||||||||
| AuthorizedOfficialFirstName: | FERNANDO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| 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 | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.