Provider Demographics
NPI:1447277405
Name:COASTAL PHYSICAL MEDICINE & REHABILITATION SERVICES, INC.
Entity type:Organization
Organization Name:COASTAL PHYSICAL MEDICINE & REHABILITATION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-633-8024
Mailing Address - Street 1:2000 NEUSE BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28560-3449
Mailing Address - Country:US
Mailing Address - Phone:252-633-8024
Mailing Address - Fax:252-633-8994
Practice Address - Street 1:2000 NEUSE BLVD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-3449
Practice Address - Country:US
Practice Address - Phone:252-633-8024
Practice Address - Fax:252-633-8994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790198EMedicaid
NC2318938Medicare PIN