Provider Demographics
NPI:1790727931
Name:MOORESVILLE SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:MOORESVILLE SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:GISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-663-7905
Mailing Address - Street 1:123 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117
Mailing Address - Country:US
Mailing Address - Phone:704-663-7905
Mailing Address - Fax:704-663-5224
Practice Address - Street 1:123 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-663-7905
Practice Address - Fax:704-663-5224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6902347Medicaid
02347OtherBC
NC6902347Medicaid