Healthcare Provider Details

I. General information

NPI: 1518090331
Provider Name (Legal Business Name): RANDOLPH GASTOENTEROLOGY CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W SALISBURY ST STE C
ASHEBORO NC
27203-5591
US

IV. Provider business mailing address

PO BOX 4485
ASHEBORO NC
27204-4485
US

V. Phone/Fax

Practice location:
  • Phone: 336-629-3313
  • Fax: 336-629-9002
Mailing address:
  • Phone: 336-629-3313
  • Fax: 336-629-9002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number9700067
License Number StateNC

VIII. Authorized Official

Name: DR. RAJESH GUPTA
Title or Position: PRESIDENT
Credential: MD
Phone: 336-629-3313