Provider Demographics
NPI:1366409484
Name:GASTON PRIMARY CARE PLLC
Entity type:Organization
Organization Name:GASTON PRIMARY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AZEMOBO
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:AKHIMIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-864-5969
Mailing Address - Street 1:PO BOX 550802
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28055-0802
Mailing Address - Country:US
Mailing Address - Phone:704-864-5969
Mailing Address - Fax:704-864-5584
Practice Address - Street 1:760 N NEW HOPE RD
Practice Address - Street 2:SUITE B
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4037
Practice Address - Country:US
Practice Address - Phone:704-864-5969
Practice Address - Fax:704-864-5584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23016207R00000X
GA51287207R00000X
NC200000171207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891255WMedicaid
NC2348418Medicare PIN
NC891255WMedicaid