Healthcare Provider Details

I. General information

NPI: 1538175393
Provider Name (Legal Business Name): NI GORSUCH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N ELAM AVE
GREENSBORO NC
27403-1118
US

IV. Provider business mailing address

415 MORRIS STREET SUITE 304
CHARLESTON WV
25301
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-1100
  • Fax:
Mailing address:
  • Phone: 304-388-7782
  • Fax: 304-388-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number201401288
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: