Healthcare Provider Details

I. General information

NPI: 1932435609
Provider Name (Legal Business Name): GASTON RADIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SUMMIT CROSSING PL STE 106
GASTONIA NC
28054-2189
US

IV. Provider business mailing address

PO BOX 1495
GASTONIA NC
28053-1495
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-8021
  • Fax: 704-864-4606
Mailing address:
  • Phone: 704-867-8021
  • Fax: 704-864-4606

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: RICHARD BLAIR KEENER
Title or Position: CEO
Credential: CPA,CMPE
Phone: 704-867-8021