Basic Information
| Provider Information | |||||||||
| NPI: | 1437106168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTON UROLOGICAL ASSOCIATES, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 631 COX RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280543438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048647764 | ||||||||
| FaxNumber: | 7048677894 | ||||||||
| Practice Location | |||||||||
| Address1: | 631 COX RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280543438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048647764 | ||||||||
| FaxNumber: | 7048677894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 06/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | CHO | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | RUFFINO | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7048647764 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RHIT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 01614 | 01 | GROUP # BCBS | OTHER | 8901614 | 05 | NC | MEDICAID |