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	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	013ET	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1306898531
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RALEIGH DURHAM MEDICAL GROUP, PA

Provider Business Mailing Address
First Line	:	5400 TRINITY RD
Second Line	:	STE 105
City	:	RALEIGH
State	:	NC
Zip	:	27607-6001
Country	:	US
Telephone Number	:	919-851-2174
Fax Number	:	919-854-7774

Provider Business Practice Location Address
First Line	:	10941 RAVEN RIDGE RD
Second Line	:	STE 105
City	:	RALEIGH
State	:	NC
Zip	:	27614-6487
Country	:	US
Telephone Number	:	919-235-0543
Fax Number	:	919-235-0542

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	DAVID K MOYE
Credential	:
Telephone Number	:	919-851-2174

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	09/21/2007

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