Basic Information
| Provider Information | |||||||||
| NPI: | 1316367691 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTONIA PHYSICIAN SERVICES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21107 | ||||||||
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| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708745400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2525 COURT DR | ||||||||
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| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048342000 | ||||||||
| FaxNumber: | 7708745483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2014 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | LARSEN | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 7708745468 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.