MEDICARE: KEITH GANCI PHD

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	103G00000X	Clinical Neuropsychologist	4800	NC

General Provider Information

NPI Number	:	1699028431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH GANCI PHD

Provider Business Mailing Address
First Line	:	2301 BRANDON CIR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-1656
Country	:	US
Telephone Number	:	631-334-1852
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 S SHARON AMITY RD
Second Line	:	STE 500
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-2896
Country	:	US
Telephone Number	:	704-362-1555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2012
Last Update Date	:	03/14/2017

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