MEDICARE: GOSHEN MEDICAL CENTER INCORPORATED

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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1548711963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOSHEN MEDICAL CENTER INCORPORATED

Provider Business Mailing Address
First Line	:	444 SW CENTER ST
Second Line	:
City	:	FAISON
State	:	NC
Zip	:	28341-8820
Country	:	US
Telephone Number	:	910-267-0421
Fax Number	:	855-996-9090

Provider Business Practice Location Address
First Line	:	4654 LONG BEACH RD SE
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-8799
Country	:	US
Telephone Number	:	910-457-0070
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. GREG BOUNDS
Credential	:
Telephone Number	:	910-267-1942

Provider Enumeration Date	:	10/20/2016
Last Update Date	:	05/29/2019

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