Healthcare Provider Details

I. General information

NPI: 1144481409
Provider Name (Legal Business Name): LAURA KATHLEEN ALTOM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 BLUE RIDGE RD STE 300
RALEIGH NC
27607-6476
US

IV. Provider business mailing address

2800 BLUE RIDGE RD STE 300
RALEIGH NC
27607-6476
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-7874
  • Fax: 919-784-2708
Mailing address:
  • Phone: 919-784-7874
  • Fax: 919-784-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD.208045
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMD.208045
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number2016-00654
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: