Healthcare Provider Details

I. General information

NPI: 1164831335
Provider Name (Legal Business Name): RALEIGH DURHAM MEDICAL GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2014
Last Update Date: 08/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14057 US HIGHWAY 17 N STE 220
HAMPSTEAD NC
28443-3770
US

IV. Provider business mailing address

5420 WADE PARK BLVD STE 106
RALEIGH NC
27607-4188
US

V. Phone/Fax

Practice location:
  • Phone: 910-270-3673
  • Fax: 910-270-0529
Mailing address:
  • Phone: 919-233-5952
  • Fax: 919-854-7774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID MOYE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 919-851-2174