Basic Information
| Provider Information | |||||||||
| NPI: | 1750457131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GABRYCH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 645 AMALIA STREET NE | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 03/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 7494 | NC | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | P01077629 | 01 | NC | MEDICARE RAILROAD | OTHER | 7413594 | 05 | NC | MEDICAID | 7779564 | 01 | NC | CIGNA | OTHER | SAT009 | 05 | SC | MEDICAID | 7591935 | 01 | NC | AETNA | OTHER | 870876 | 01 | SC | WELLCARE OF SC | OTHER | 1464G | 01 | NC | BCBS-NC | OTHER |