Healthcare Provider Details

I. General information

NPI: 1174696363
Provider Name (Legal Business Name): RACHID IDRISSI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL DR
BENSON NC
27504-1177
US

IV. Provider business mailing address

1 MEDICAL DR
BENSON NC
27504-1177
US

V. Phone/Fax

Practice location:
  • Phone: 919-894-1740
  • Fax: 919-894-2701
Mailing address:
  • Phone: 919-894-1740
  • Fax: 919-894-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number058038
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number200700587
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: