Provider Demographics
NPI:1528190410
Name:INTERNAL MEDICINE ASSOCIATES OF GASTONIA PA
Entity Type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF GASTONIA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLARREAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-853-3330
Mailing Address - Street 1:2391 COURT DR STE 110
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2197
Mailing Address - Country:US
Mailing Address - Phone:704-853-3330
Mailing Address - Fax:704-853-8951
Practice Address - Street 1:2391 COURT DR STE 110
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2197
Practice Address - Country:US
Practice Address - Phone:704-853-3330
Practice Address - Fax:704-853-8951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2013-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2335700Medicare ID - Type Unspecified