Basic Information
| Provider Information | |||||||||
| NPI: | 1922061902 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID CAROLINA GASTROENTEROLOGY ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 DENNIS DR | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273306343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197744511 | ||||||||
| FaxNumber: | 9197743196 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 DENNIS DR | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273306343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197744511 | ||||||||
| FaxNumber: | 9197743196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | PATE | ||||||||
| AuthorizedOfficialFirstName: | MARION | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9197744511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 0195A | 01 | NC | BLUECROSS | OTHER | 890195A | 05 | NC | MEDICAID |