Provider Demographics
NPI:1750407128
Name:GOSHEN MEDICAL CENTER INCORPORATED
Entity type:Organization
Organization Name:GOSHEN MEDICAL CENTER INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:REBA
Authorized Official - Middle Name:W
Authorized Official - Last Name:FUTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-267-9997
Mailing Address - Street 1:412 SW CENTER ST
Mailing Address - Street 2:
Mailing Address - City:FAISON
Mailing Address - State:NC
Mailing Address - Zip Code:28341-8820
Mailing Address - Country:US
Mailing Address - Phone:910-267-0421
Mailing Address - Fax:910-267-0441
Practice Address - Street 1:104 E LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NC
Practice Address - Zip Code:28585-8893
Practice Address - Country:US
Practice Address - Phone:252-448-4321
Practice Address - Fax:252-448-1073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
341909Medicare ID - Type UnspecifiedUGS