Provider Demographics
NPI:1215932215
Name:GASTON FAMILY HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:GASTON FAMILY HEALTH SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS SERVICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARMILA
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-874-1907
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:
Practice Address - Street 1:991 WEST HUDSON BOULEVARD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-6430
Practice Address - Country:US
Practice Address - Phone:704-853-5079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GASTON FAMILY HEALTH SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-16
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC611963200OtherBLACK LUNG PROGRAM
NC0136XOtherBLUE CROSS NUMBER
SCNPB239Medicaid
NC344574AMedicaid
SCNPB239Medicaid