Healthcare Provider Details

I. General information

NPI: 1407734031
Provider Name (Legal Business Name): SAMARITAN SPORTS MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 FALLS OF NEUSE RD STE 110
RALEIGH NC
27615-3450
US

IV. Provider business mailing address

8300 FALLS OF NEUSE RD STE 110
RALEIGH NC
27615-3450
US

V. Phone/Fax

Practice location:
  • Phone: 919-648-0618
  • Fax:
Mailing address:
  • Phone: 919-648-0618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN MARTIN PETTY
Title or Position: OWNER
Credential: MD
Phone: 919-648-0618