Basic Information
Provider Information | |||||||||
NPI: | 1952394108 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GASQUE | ||||||||
FirstName: | BOYD | ||||||||
MiddleName: | BENNETT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 1527 | ||||||||
Address2: |   | ||||||||
City: | LUMBERTON | ||||||||
State: | NC | ||||||||
PostalCode: | 283591527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9107388222 | ||||||||
FaxNumber: | 9106710846 | ||||||||
Practice Location | |||||||||
Address1: | 209 WEST 27TH STREET | ||||||||
Address2: |   | ||||||||
City: | LUMBERTON | ||||||||
State: | NC | ||||||||
PostalCode: | 283583016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9107388222 | ||||||||
FaxNumber: | 9106710846 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2005 | ||||||||
LastUpdateDate: | 07/20/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 000021779 | NC | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 21779 | NC | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 8934956 | 05 | NC |   | MEDICAID | 34956 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |