Provider Demographics
NPI:1134322522
Name:FAIRGROVE RADIATION ONCOLOGY, PA
Entity type:Organization
Organization Name:FAIRGROVE RADIATION ONCOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GAYLA
Authorized Official - Middle Name:S
Authorized Official - Last Name:LOWERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-878-4615
Mailing Address - Street 1:PO BOX 6297
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28687-6297
Mailing Address - Country:US
Mailing Address - Phone:704-878-4615
Mailing Address - Fax:704-878-7193
Practice Address - Street 1:557 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4107
Practice Address - Country:US
Practice Address - Phone:704-878-4615
Practice Address - Fax:704-878-7193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890153GMedicaid
NC230837Medicare ID - Type UnspecifiedGROUP PROVIDER