Healthcare Provider Details

I. General information

NPI: 1356324487
Provider Name (Legal Business Name): GASTON RADIOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SUMMIT CROSSING PL STE 106
GASTONIA NC
28054-2176
US

IV. Provider business mailing address

PO BOX 745431
ATLANTA GA
30374-5431
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-8021
  • Fax: 704-864-4606
Mailing address:
  • Phone: 843-449-5360
  • Fax: 706-653-4711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ERIC JAX
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 704-867-8021