Basic Information
| Provider Information | |||||||||
| NPI: | 1598297806 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROWAN DIAGNOSTIC CLINIC, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 MOCKSVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281442705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046337220 | ||||||||
| FaxNumber: | 7046470515 | ||||||||
| Practice Location | |||||||||
| Address1: | 1809 BRENNER AVE | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281442558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042167071 | ||||||||
| FaxNumber: | 7046470515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2017 | ||||||||
| LastUpdateDate: | 01/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | VERHAEGHE | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7046337220 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ROWAN DIAGNOSTIC CLINIC, PA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 89-02575 | 05 | NC | MEDICAID |