Healthcare Provider Details

I. General information

NPI: 1194096289
Provider Name (Legal Business Name): RALEIGH DURHAM MEDICAL GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 WEEKS DR
ROXBORO NC
27573-3933
US

IV. Provider business mailing address

5420 WADE PARK BLVD STE 106
RALEIGH NC
27607-4188
US

V. Phone/Fax

Practice location:
  • Phone: 336-598-5480
  • Fax: 336-598-5482
Mailing address:
  • Phone: 919-233-5952
  • Fax: 919-854-7774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID MOYE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 919-851-2174