NPIMap

Organization Active NPI

Intracoastal Internal Medicine

  • Internal Medicine Physician
  • Wilmington, NC
National Provider Identifier
1770515272
Registry record updated Jun 19, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
Legal business name
INTRACOASTAL INTERNAL MEDICINE
Practice address
2580 Pickard Rd
Wilmington, NC 28403-4461
Phone
(910) 332-0701
Fax
(910) 332-0710
NPI assigned
Jul 7, 2006
Last updated
Jun 19, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 19, 2019

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

Authorized official

Name
Kimberly Dahlstrom
Title
Admin Asst
Phone
(910) 332-0701

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207R00000X Primary

Addresses

Primary practice location

2580 Pickard Rd
Wilmington, NC 28403-4461

Mailing address

2580 Pickard Rd
Wilmington, NC 28403-4461
Phone (910) 332-0701

Other identifiers 7

IdentifierTypeStateIssuer
5903216MedicaidNC
7005481MedicaidNC
7005555MedicaidNC
1467917880MedicaidNC
1447204631MedicaidNC
891069VMedicaidNC
8911484MedicaidNC

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060921000486 NC Part B Supplier - Clinic/Group Practice 2668477878 Receives reassigned benefits from 7 practitioners
Practice locations: Wilmington, NC

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
34D1051890Intracoastal Internal Medicine PA2580 Pickard Road, Wilmington, NC 28403Certificate of waiverMar 13, 2028

National Provider Directory

National Provider Directory

Locations

2580 Pickard Rd
Wilmington, NC 28403
Phone (910) 332-0701

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/IIJBAA

Practitioners & affiliated clinicians

Practitioners 8

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": "1152230400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1560902400000",
    "number": "1770515272",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2580 PICKARD RD",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284034461",
            "telephone_number": "910-332-0701",
            "fax_number": "910-332-0710"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2580 PICKARD RD",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284034461",
            "telephone_number": "910-332-0701",
            "fax_number": "910-332-0710"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTRACOASTAL INTERNAL MEDICINE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-07",
        "last_updated": "2019-06-19",
        "status": "A",
        "authorized_official_last_name": "DAHLSTROM",
        "authorized_official_first_name": "KIMBERLY",
        "authorized_official_title_or_position": "ADMIN ASST",
        "authorized_official_telephone_number": "910-332-0701"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5903216",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7005481",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7005555",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1467917880",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1447204631",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "891069V",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8911484",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Wilmington, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 19, 2019; 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.