Healthcare Provider Details

I. General information

NPI: 1497520654
Provider Name (Legal Business Name): PROVIDER HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 DRESSER CT STE 102
RALEIGH NC
27609-7325
US

IV. Provider business mailing address

1004 DRESSER CT STE 102
RALEIGH NC
27609-7325
US

V. Phone/Fax

Practice location:
  • Phone: 919-654-7309
  • Fax:
Mailing address:
  • Phone: 919-654-7309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SHARON MENDENHALL
Title or Position: QUALITY / COMPLIANCE MANAGER
Credential:
Phone: 919-654-7309