Provider Demographics
NPI:1912022369
Name:GOSHEN MEDICAL CENTER INCORPORATED
Entity Type:Organization
Organization Name:GOSHEN MEDICAL CENTER INCORPORATED
Other - Org Name:GOSHEN MEDICAL CENTER WALLACE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE ASSISTANT/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:REBA
Authorized Official - Middle Name:W
Authorized Official - Last Name:FUTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-267-8252
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:FAISON
Mailing Address - State:NC
Mailing Address - Zip Code:28341-0187
Mailing Address - Country:US
Mailing Address - Phone:910-267-0421
Mailing Address - Fax:910-267-0441
Practice Address - Street 1:110 EASTWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-9236
Practice Address - Country:US
Practice Address - Phone:910-285-2330
Practice Address - Fax:910-285-3060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344011AMedicaid
NC344011AMedicaid