1407028756 NPI number — RALEIGH SPINE CENTER, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407028756 NPI number — RALEIGH SPINE CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RALEIGH SPINE CENTER, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407028756
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 CRUTCHFIELD ST
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27704-2771
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-620-7900
Provider Business Mailing Address Fax Number:
919-479-5061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 ROCK QUARRY RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27610-4100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-620-7900
Provider Business Practice Location Address Fax Number:
919-479-5061
Provider Enumeration Date:
03/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEGROW
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
919-620-7900

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1958 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 08513 . This is a "BCBS PROVIDER ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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