Provider Demographics
NPI:1104977198
Name:COASTAL MEDICAL TRANSPORT, INC
Entity type:Organization
Organization Name:COASTAL MEDICAL TRANSPORT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZEMORE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:252-794-4149
Mailing Address - Street 1:101 S GRANVILLE ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NC
Mailing Address - Zip Code:27983-2148
Mailing Address - Country:US
Mailing Address - Phone:252-794-4149
Mailing Address - Fax:252-794-3477
Practice Address - Street 1:101 S GRANVILLE ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-2148
Practice Address - Country:US
Practice Address - Phone:252-794-4149
Practice Address - Fax:252-794-3477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15563416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0729ROtherBLUECROSS BLUE SHIELD
NC3406822Medicaid
NC2783072Medicare PIN