Basic Information
| Provider Information | |||||||||
| NPI: | 1669401964 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA COAST PRIMARY MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 148 | ||||||||
| Address2: | |||||||||
| City: | KENANSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283490148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102961087 | ||||||||
| FaxNumber: | 9102961086 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 N NC 24 & 50 HWY | ||||||||
| Address2: | |||||||||
| City: | KENANSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283490148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102961087 | ||||||||
| FaxNumber: | 9102961086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 11/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | BERTHA1 | ||||||||
| AuthorizedOfficialMiddleName: | TAYLOR- | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9102961087 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11515 | 01 | NC | BCBS | OTHER | 5900323 | 05 | NC | MEDICAID |