MEDICARE: GOLDSBORO MEDICAL SPECIALISTS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM2500X	Medical Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01643	OTHER	NC	BLUE CR OSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770552069
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDSBORO MEDICAL SPECIALISTS PA

Provider Business Mailing Address
First Line	:	201 COX BLVD
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27534-9479
Country	:	US
Telephone Number	:	919-734-9455
Fax Number	:	919-734-4769

Provider Business Practice Location Address
First Line	:	201 COX BLVD
Second Line	:
City	:	GOLDSBORO
State	:	NC
Zip	:	27534-9479
Country	:	US
Telephone Number	:	919-734-9455
Fax Number	:	919-734-4769

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	DR. WILLIAM JAMES STACKHOUSE
Credential	:	MD
Telephone Number	:	919-734-9455

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	08/12/2010

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