Basic Information
| Provider Information | |||||||||
| NPI: | 1578061131 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOSHEN MEDICAL CENTER, INCORPORATED | ||||||||
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| OtherOrganizationName: | GOSHEN MEDICAL CENTER - GRANTSBORO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 187 | ||||||||
| Address2: | |||||||||
| City: | FAISON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283410187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102672042 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11179C HIGHWAY 55 | ||||||||
| Address2: | |||||||||
| City: | GRANTSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102672042 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2018 | ||||||||
| LastUpdateDate: | 01/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | BOUNDS | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9102671237 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.