Provider Demographics
NPI:1023048279
Name:GASTONIA MEDICAL SPECIALTY CLINIC PA
Entity type:Organization
Organization Name:GASTONIA MEDICAL SPECIALTY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER - PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIKELL
Authorized Official - Middle Name:J
Authorized Official - Last Name:JARRATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-867-2341
Mailing Address - Street 1:1021 X RAY DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7489
Mailing Address - Country:US
Mailing Address - Phone:704-867-2341
Mailing Address - Fax:704-867-9019
Practice Address - Street 1:1021 X RAY DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7489
Practice Address - Country:US
Practice Address - Phone:704-867-2341
Practice Address - Fax:704-867-9019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01627OtherBCBSNC GROUP PROVIDER #
SCNPA701Medicaid
NCCC5252OtherRAILROAD MEDICARE
NC5920537Medicaid
NC01627OtherBCBSNC GROUP PROVIDER #