Healthcare Provider Details

I. General information

NPI: 1548346331
Provider Name (Legal Business Name): MED ONE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 03/07/2023
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7019-200 HARPS MILL RD.
RALEIGH NC
27615
US

IV. Provider business mailing address

7019-200 HARPS MILL RD.
RALEIGH NC
27615
US

V. Phone/Fax

Practice location:
  • Phone: 919-850-1300
  • Fax: 919-850-0012
Mailing address:
  • Phone: 919-850-1300
  • Fax: 919-850-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2394
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number930076
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0050-02018
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201835
License Number StateNC

VIII. Authorized Official

Name: MS. TIFFANY L. CONNER
Title or Position: INSURANCE AND BILLING MANAGER
Credential:
Phone: 919-850-1300