1316082357 NPI number — RALEIGH DURHAM MEDICAL GROUP PA

Table of content: (NPI 1316082357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316082357 NPI number — RALEIGH DURHAM MEDICAL GROUP PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RALEIGH DURHAM MEDICAL GROUP PA
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:
6
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:
1316082357
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5420 WADE PARK BLVD
Provider Second Line Business Mailing Address:
STE 106
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27607-4188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-851-2174
Provider Business Mailing Address Fax Number:
919-854-7774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 DURALEIGH RD
Provider Second Line Business Practice Location Address:
STE 307
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27612-8106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-232-0050
Provider Business Practice Location Address Fax Number:
919-232-0060
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOYE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR VP
Authorized Official Telephone Number:
919-851-2174

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 144TM . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 891137F , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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