Basic Information
| Provider Information | |||||||||
| NPI: | 1538210760 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOCO SURGICAL ASSOCIATES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 HIGHLAND OAKS DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271037105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367684710 | ||||||||
| FaxNumber: | 3366599845 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 HIGHLAND OAKS DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271037105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367684710 | ||||||||
| FaxNumber: | 3366599845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 04/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | KELLAM | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3366599440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 9600966 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0191H | 01 | NC | BCBS OF NC | OTHER | 890191H | 05 | NC | MEDICAID |