Provider Demographics
NPI:1114221181
Name:GASTONIA MEDICAL SPECIALTY CLINIC PA
Entity Type:Organization
Organization Name:GASTONIA MEDICAL SPECIALTY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANUP
Authorized Official - Middle Name:
Authorized Official - Last Name:BANERJEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-867-2341
Mailing Address - Street 1:1021 X RAY DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7489
Mailing Address - Country:US
Mailing Address - Phone:704-867-2341
Mailing Address - Fax:704-867-9019
Practice Address - Street 1:1021 X RAY DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7489
Practice Address - Country:US
Practice Address - Phone:704-867-2341
Practice Address - Fax:704-867-9019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01627OtherBCBSNC