Healthcare Provider Details

I. General information

NPI: 1669732640
Provider Name (Legal Business Name): ELIZABETH GRACE JARVIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 NEW BERN AVE
RALEIGH NC
27610-1247
US

IV. Provider business mailing address

2920 HIGHWOODS BLVD
RALEIGH NC
27604-0010
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-7844
  • Fax:
Mailing address:
  • Phone: 877-498-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number182692
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2016-00692
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: