Provider Demographics
NPI:1801001201
Name:MID CAROLINA SURGICAL CLINIC PA
Entity Type:Organization
Organization Name:MID CAROLINA SURGICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-775-3321
Mailing Address - Street 1:709B WICKER ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4142
Mailing Address - Country:US
Mailing Address - Phone:919-775-3321
Mailing Address - Fax:919-774-6974
Practice Address - Street 1:709B WICKER ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4142
Practice Address - Country:US
Practice Address - Phone:919-775-3321
Practice Address - Fax:919-774-6974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13991174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
36308OtherBCBS
NC8936308Medicaid
0170COtherBCBS
206715AMedicare ID - Type Unspecified
0170COtherBCBS