Provider Demographics
NPI:1770515272
Name:INTRACOASTAL INTERNAL MEDICINE
Entity type:Organization
Organization Name:INTRACOASTAL INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAHLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-332-0701
Mailing Address - Street 1:2580 PICKARD RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-4461
Mailing Address - Country:US
Mailing Address - Phone:910-332-0701
Mailing Address - Fax:910-332-0710
Practice Address - Street 1:2580 PICKARD RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4461
Practice Address - Country:US
Practice Address - Phone:910-332-0701
Practice Address - Fax:910-332-0710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903216Medicaid
NC7005481Medicaid
NC7005555Medicaid
NC1467917880Medicaid
NC1447204631Medicaid
NC891069VMedicaid
NC8911484Medicaid