1912170002 NPI number — GOSHEN MEDICAL CENTER INCORPORATED

Table of content: (NPI 1912170002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912170002 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:
GOSHEN MEDICAL CENTER GARLAND
Provider Other Organization Name Type Code:
3
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:
1912170002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 187
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:
28341-0187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-267-0421
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 SOUTH LISBON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARLAND
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28441-0398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-529-1827
Provider Business Practice Location Address Fax Number:
910-529-1873
Provider Enumeration Date:
04/09/2008

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:
910-267-1942

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)





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