Basic Information
| Provider Information | |||||||||
| NPI: | 1467466961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORETSKY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1025 MOREHEAD MEDICAL DR | ||||||||
| Address2: | SUITE 275 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044032662 | ||||||||
| FaxNumber: | 7044032670 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 MOREHEAD MEDICAL DR | ||||||||
| Address2: | SUITE 275 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044032662 | ||||||||
| FaxNumber: | 7044032670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | 2014-02561 | NC | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086S0120X | 0101225774 | VA | N | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | NC2352 | 05 | SC | MEDICAID | 1467466961 | 05 | NC | MEDICAID | 280541 | 01 | VA | MAMSI/OPTIMUM CHOICE | OTHER | 7712078 | 01 | VA | AETNA | OTHER | 3116108340003E | 01 | VA | CIGNA | OTHER | 280541 | 01 | VA | ALLIANCE/MDIPA | OTHER | 006704441 | 05 | VA | MEDICAID | 216623 | 01 | VA | ANTHEM BCBS | OTHER | 26053 | 01 | VA | OPTIMA/SENTARA HEATLH | OTHER | 311610834 | 01 | VA | NC HEALTH CHOICE | OTHER | 89063AN | 01 | VA | NORTH CAROLINA MEDICAID | OTHER | 89063AN | 05 | NC | MEDICAID |