MEDICARE: RALEIGH DURHAM MEDICAL GROUP, PA

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	027M3	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1053656132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RALEIGH DURHAM MEDICAL GROUP, PA

Provider Business Mailing Address
First Line	:	5420 WADE PARK BLVD
Second Line	:	STE 106
City	:	RALEIGH
State	:	NC
Zip	:	27607-4188
Country	:	US
Telephone Number	:	919-233-5952
Fax Number	:	919-854-7774

Provider Business Practice Location Address
First Line	:	211 W MATTHEWS ST
Second Line	:	STE 102
City	:	MATTHEWS
State	:	NC
Zip	:	28105-1309
Country	:	US
Telephone Number	:	704-708-4301
Fax Number	:	704-708-4389

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DAVID K MOYE
Credential	:
Telephone Number	:	919-233-5952

Provider Enumeration Date	:	11/30/2012
Last Update Date	:	02/05/2014

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