Provider Demographics
NPI:1215242755
Name:COASTAL PLASTIC SURGERY LTD
Entity type:Organization
Organization Name:COASTAL PLASTIC SURGERY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CARWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:757-481-7788
Mailing Address - Street 1:1200 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2274
Mailing Address - Country:US
Mailing Address - Phone:757-481-7788
Mailing Address - Fax:757-481-1707
Practice Address - Street 1:1200 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2274
Practice Address - Country:US
Practice Address - Phone:757-481-7788
Practice Address - Fax:757-481-1707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010257262086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty