1356324487 NPI number — GASTON RADIOLOGY PA

Table of content: (NPI 1356324487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356324487 NPI number — GASTON RADIOLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTON RADIOLOGY PA
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:
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:
1356324487
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 745431
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-5431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-449-5360
Provider Business Mailing Address Fax Number:
706-653-4711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 SUMMIT CROSSING PL
Provider Second Line Business Practice Location Address:
STE 106
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28054-2176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-867-8021
Provider Business Practice Location Address Fax Number:
704-864-4606
Provider Enumeration Date:
11/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JAX
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
704-867-8021

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0067971 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8901618 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01618 . This is a "BLUE CROSS BLUE SHIELD NC" identifier . This identifiers is of the category "OTHER".
  • Identifier: CC8346 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8381530 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1702 . This is a "PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: E01618 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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