NPIMap

Organization Active NPI

Dermatology Associates of Coastal Carolina

  • Clinical & Laboratory Dermatological Immunology Physician
  • Jacksonville, NC
National Provider Identifier
1033459011
Registry record updated Sep 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical & Laboratory Dermatological Immunology PhysicianTaxonomy code 207NI0002X
Legal business name
DERMATOLOGY ASSOCIATES OF COASTAL CAROLINA
Practice address
2145 Country Club Rd
Jacksonville, NC 28546-2403
Phone
(252) 633-4461
Fax
(252) 633-6016
NPI assigned
Feb 27, 2013
Last updated
Sep 21, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 21, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. James Polo, M.D.NPI 1093731168
Title
MD/Owner
Phone
(252) 633-4461

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical & Laboratory Dermatological Immunology Physician 207NI0002X Primary

Addresses

Primary practice location

2145 Country Club Rd
Jacksonville, NC 28546-2403

Mailing address

PO Box 890283
Charlotte, NC 28289-0283
Phone (252) 633-4461

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060828000107 NC Part B Supplier - Clinic/Group Practice 1658375092 Receives reassigned benefits from 20 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Jacksonville, NC; Kinston, NC; Morehead City, NC; New Bern, NC

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D2056673Dermatology Associates of Coastal Carolina2145 Country Club Rd, Suite 100, Jacksonville, NC 28546ComplianceMar 26, 2028

National Provider Directory

National Provider Directory

Locations

39A Office Park Dr
Jacksonville, NC 28546
Phone (252) 633-4461

3332 Bridges St
Ste B
Morehead City, NC 28557
Phone (252) 622-4378

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1361923200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1663718400000",
    "number": "1033459011",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 890283",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282890283",
            "telephone_number": "252-633-4461",
            "fax_number": "252-633-6016"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2145 COUNTRY CLUB RD",
            "city": "JACKSONVILLE",
            "state": "NC",
            "postal_code": "285462403",
            "telephone_number": "252-633-4461",
            "fax_number": "252-633-6016"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DERMATOLOGY ASSOCIATES OF COASTAL CAROLINA",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-02-27",
        "last_updated": "2022-09-21",
        "certification_date": "2022-09-21",
        "status": "A",
        "authorized_official_last_name": "POLO",
        "authorized_official_first_name": "JAMES",
        "authorized_official_title_or_position": "MD/OWNER",
        "authorized_official_telephone_number": "252-633-4461",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207NI0002X",
            "taxonomy_group": "",
            "desc": "Dermatology, Clinical & Laboratory Dermatological Immunology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.