Healthcare Provider Details

I. General information

NPI: 1770224875
Provider Name (Legal Business Name): PRIVATE DIAGNOSTIC CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DUKE HEALTH CARY PLACE SUITE 120
CARY NC
27519
US

IV. Provider business mailing address

PO BOX 110566
DURHAM NC
27709-5566
US

V. Phone/Fax

Practice location:
  • Phone: 919-385-8120
  • Fax: 919-385-9500
Mailing address:
  • Phone: 919-620-4855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER THOMAS FREDERICK
Title or Position: CFO
Credential:
Phone: 919-613-7762