Provider Demographics
NPI:1427106079
Name:COASTAL FAMILY PRACTICE & INTERNAL MEDICINE
Entity type:Organization
Organization Name:COASTAL FAMILY PRACTICE & INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BIBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-763-3481
Mailing Address - Street 1:2207 DELANEY AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6010
Mailing Address - Country:US
Mailing Address - Phone:910-763-3481
Mailing Address - Fax:910-763-3485
Practice Address - Street 1:2207 DELANEY AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6010
Practice Address - Country:US
Practice Address - Phone:910-763-3481
Practice Address - Fax:910-763-3485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC101625207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014HVMedicaid
NC014HVOtherBCBS
NC89014HVMedicaid
S25558Medicare UPIN