Provider Demographics
NPI:1902094485
Name:COASTAL PAIN MEDICINE, LLC
Entity Type:Organization
Organization Name:COASTAL PAIN MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:GRUBB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-418-0333
Mailing Address - Street 1:PO BOX 30692
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-0692
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:888-418-0333
Practice Address - Street 1:2905 GROVELAND DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-7188
Practice Address - Country:US
Practice Address - Phone:888-418-0333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
019PKOtherBCBS
019PKOtherBCBS