1083739429 NPI number — GOSHEN MEDICAL CENTER INCORPORATED

Table of content: (NPI 1083739429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083739429 NPI number — GOSHEN MEDICAL CENTER INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOSHEN MEDICAL CENTER INCORPORATED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083739429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
412 SW CENTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAISON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28341-8820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-267-0421
Provider Business Mailing Address Fax Number:
910-267-0441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 W. ASH ST.
Provider Second Line Business Practice Location Address:
STE#202
Provider Business Practice Location Address City Name:
GOLDSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27530-3679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-731-4941
Provider Business Practice Location Address Fax Number:
919-731-2416
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FUTRELL
Authorized Official First Name:
REBA
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
EXECUTIVE ASSISTANT CREDENTIALING
Authorized Official Telephone Number:
910-267-9997

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 344010A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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