Provider Demographics
NPI:1639156714
Name:GASTONIA CHILDREN'S CLINIC, P.A.
Entity Type:Organization
Organization Name:GASTONIA CHILDREN'S CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-867-5356
Mailing Address - Street 1:2544 COURT DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3450
Mailing Address - Country:US
Mailing Address - Phone:704-867-5356
Mailing Address - Fax:704-867-4990
Practice Address - Street 1:2544 COURT DR
Practice Address - Street 2:SUITE C
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3450
Practice Address - Country:US
Practice Address - Phone:704-867-5356
Practice Address - Fax:704-867-4990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty