Provider Demographics
NPI:1487170387
Name:COASTAL CAROLINA PATHOLOGY, PA
Entity type:Organization
Organization Name:COASTAL CAROLINA PATHOLOGY, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-395-4441
Mailing Address - Street 1:2606 IRON GATE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2494
Mailing Address - Country:US
Mailing Address - Phone:910-395-4441
Mailing Address - Fax:910-395-7074
Practice Address - Street 1:2606 IRON GATE DR STE 201
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2494
Practice Address - Country:US
Practice Address - Phone:910-395-4441
Practice Address - Fax:910-395-7074
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COASTAL CAROLINA PATHOLOGY, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7001210Medicaid