Healthcare Provider Details

I. General information

NPI: 1255601407
Provider Name (Legal Business Name): CREEKSIDE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2042 CREEKSIDE LANDING DR
APEX NC
27502-3982
US

IV. Provider business mailing address

2042 CREEKSIDE LANDING DR
APEX NC
27502-3982
US

V. Phone/Fax

Practice location:
  • Phone: 919-554-6756
  • Fax:
Mailing address:
  • Phone: 919-554-6756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: HENRY NEWTON PLEASANT
Title or Position: DIRECTOR
Credential: MD
Phone: 919-554-6754