Provider Demographics
NPI:1912170002
Name:GOSHEN MEDICAL CENTER INCORPORATED
Entity Type:Organization
Organization Name:GOSHEN MEDICAL CENTER INCORPORATED
Other - Org Name:GOSHEN MEDICAL CENTER GARLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE ASSISTANT/CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBA
Authorized Official - Middle Name:W
Authorized Official - Last Name:FUTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-267-1942
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:
Practice Address - Street 1:105 SOUTH LISBON AVENUE
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:NC
Practice Address - Zip Code:28441-0398
Practice Address - Country:US
Practice Address - Phone:910-529-1827
Practice Address - Fax:910-529-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
341955Medicare Oscar/Certification