Provider Demographics
NPI:1992974042
Name:GASTON FAMILY MEDICINE, P. A.
Entity type:Organization
Organization Name:GASTON FAMILY MEDICINE, P. A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:704-824-9119
Mailing Address - Street 1:PO BOX 551178
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28055-1178
Mailing Address - Country:US
Mailing Address - Phone:704-824-9119
Mailing Address - Fax:704-824-2401
Practice Address - Street 1:3845 SOUTH NEW HOPE ROAD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28056-8439
Practice Address - Country:US
Practice Address - Phone:704-824-9119
Practice Address - Fax:704-824-2401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8919982Medicaid
NC19982OtherBCBS
NCP00297412OtherPALMETTO GBA
NC8919982Medicaid
NC205144BMedicare PIN