Provider Demographics
NPI:1255592002
Name:MID CAROLINA GASTROENTEROLOGY ASSOCIATES, PA
Entity type:Organization
Organization Name:MID CAROLINA GASTROENTEROLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARION
Authorized Official - Middle Name:BUTLER
Authorized Official - Last Name:PATE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:919-774-4511
Mailing Address - Street 1:110 DENNIS DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-6343
Mailing Address - Country:US
Mailing Address - Phone:919-774-4511
Mailing Address - Fax:919-774-3196
Practice Address - Street 1:110 DENNIS DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-6343
Practice Address - Country:US
Practice Address - Phone:919-774-4511
Practice Address - Fax:919-774-3196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAS0094261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34C0001125OtherASC IDENTIFICATION NUMBER
NC34C0001125OtherASC IDENTIFICATION NUMBER