Healthcare Provider Details

I. General information

NPI: 1548680366
Provider Name (Legal Business Name): THOMAS ELLIOTT PENDERGRAST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2014
Last Update Date: 04/30/2023
Certification Date: 04/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 BLUE RIDGE RD STE 100
RALEIGH NC
27612-8087
US

IV. Provider business mailing address

5220 GREENS DAIRY RD
RALEIGH NC
27616-4612
US

V. Phone/Fax

Practice location:
  • Phone: 919-256-3576
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101271086
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2020-00123
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: