Provider Demographics
NPI:1144312075
Name:GATEWAY AMBULATORY SURGERY CENTER LLC
Entity type:Organization
Organization Name:GATEWAY AMBULATORY SURGERY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:NANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-783-3000
Mailing Address - Street 1:1025 NORTHEAST GATEWAY COURT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025
Mailing Address - Country:US
Mailing Address - Phone:704-920-7020
Mailing Address - Fax:704-920-7063
Practice Address - Street 1:1025 NORTHEAST GATEWAY COURT
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2440
Practice Address - Country:US
Practice Address - Phone:704-920-7020
Practice Address - Fax:704-920-7063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAS0070261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2333283Medicare ID - Type UnspecifiedCRNA GROUP