Healthcare Provider Details

I. General information

NPI: 1740567551
Provider Name (Legal Business Name): IDLER SPINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 EXECUTIVE DR SUITE 103
RALEIGH NC
27609-7450
US

IV. Provider business mailing address

3410 EXECUTIVE DR SUITE 103
RALEIGH NC
27609-7450
US

V. Phone/Fax

Practice location:
  • Phone: 919-872-5296
  • Fax: 919-850-9718
Mailing address:
  • Phone: 919-872-5296
  • Fax: 919-850-9718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number2008-00472
License Number StateNC

VIII. Authorized Official

Name: CARY S IDLER
Title or Position: OWNER
Credential: MD
Phone: 919-872-5296