Provider Demographics
NPI:1356324487
Name:GASTON RADIOLOGY PA
Entity Type:Organization
Organization Name:GASTON RADIOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:JAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-592-8186
Mailing Address - Street 1:PO BOX 745431
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-5431
Mailing Address - Country:US
Mailing Address - Phone:843-449-5360
Mailing Address - Fax:706-653-4711
Practice Address - Street 1:620 SUMMIT CROSSING PL
Practice Address - Street 2:STE 106
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2176
Practice Address - Country:US
Practice Address - Phone:704-867-8021
Practice Address - Fax:704-864-4606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0067971OtherAETNA HMO
8381530OtherAETNA PPO
SCE01618Medicaid
01618OtherBLUE CROSS BLUE SHIELD NC
1702OtherPARTNERS
NC8901618Medicaid
CC8346OtherRAILROAD MEDICARE
0067971OtherAETNA HMO