Provider Demographics
NPI:1447638341
Name:COASTAL PEDIATRIC ASSOCIATES, PLLC
Entity type:Organization
Organization Name:COASTAL PEDIATRIC ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-202-8020
Mailing Address - Street 1:3505 CONVERSE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6131
Mailing Address - Country:US
Mailing Address - Phone:910-392-5634
Mailing Address - Fax:910-777-2022
Practice Address - Street 1:3505 CONVERSE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6131
Practice Address - Country:US
Practice Address - Phone:910-392-5634
Practice Address - Fax:910-777-2022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17469174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty