Provider Demographics
NPI:1689761546
Name:GATEWAY AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:GATEWAY AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BASHORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-920-7027
Mailing Address - Street 1:1025 NORTHEAST GATEWAY COURT, NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025
Mailing Address - Country:US
Mailing Address - Phone:704-920-7020
Mailing Address - Fax:704-920-7063
Practice Address - Street 1:1025 NORTHEAST GATEWAY COURT, NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025
Practice Address - Country:US
Practice Address - Phone:704-920-7020
Practice Address - Fax:704-920-7063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAS0070261Q00000X
NC060202261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409938Medicaid
NC3409938Medicaid