Healthcare Provider Details

I. General information

NPI: 1649517616
Provider Name (Legal Business Name): DUKE HOSPITAL OUTPATIENT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2013
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MEDICINE CIR
DURHAM NC
27710-0001
US

IV. Provider business mailing address

11726 BROADFIELD CT
RALEIGH NC
27617-4254
US

V. Phone/Fax

Practice location:
  • Phone: 919-668-1219
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number5005980
License Number StateNC

VIII. Authorized Official

Name: MRS. NICOLE JELESOFF
Title or Position: MD
Credential:
Phone: 919-668-1219