Basic Information
| Provider Information | |||||||||
| NPI: | 1598143836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOSHEN MEDICAL CENTER INCORPORATED | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOSHEN MEDICAL CENTER - CHADBOURN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 187 | ||||||||
| Address2: | |||||||||
| City: | FAISON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283410187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102670421 | ||||||||
| FaxNumber: | 9102678683 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 N BROWN ST | ||||||||
| Address2: | |||||||||
| City: | CHADBOURN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284311716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106541701 | ||||||||
| FaxNumber: | 9102678934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2015 | ||||||||
| LastUpdateDate: | 05/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 9102678252 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GOSHEN MEDICAL CENTER INCORPORATED | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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.