Healthcare Provider Details

I. General information

NPI: 1033218045
Provider Name (Legal Business Name): AVALON MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CONNER DR STE 402
CHAPEL HILL NC
27514-7038
US

IV. Provider business mailing address

101 CONNER DR STE 402
CHAPEL HILL NC
27514-7038
US

V. Phone/Fax

Practice location:
  • Phone: 919-928-1146
  • Fax: 919-928-1148
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9700235
License Number StateNC

VIII. Authorized Official

Name: MR. RICHARD R DILALLA
Title or Position: PRACTICE MANAGER
Credential:
Phone: 919-928-1146