Provider Demographics
NPI:1518090331
Name:RANDOLPH GASTOENTEROLOGY CENTER PA
Entity Type:Organization
Organization Name:RANDOLPH GASTOENTEROLOGY CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJESH
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-629-3313
Mailing Address - Street 1:PO BOX 4485
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27204-4485
Mailing Address - Country:US
Mailing Address - Phone:336-629-3313
Mailing Address - Fax:336-629-9002
Practice Address - Street 1:600 W SALISBURY ST STE C
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5591
Practice Address - Country:US
Practice Address - Phone:336-629-3313
Practice Address - Fax:336-629-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700067207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891145QMedicaid