Healthcare Provider Details

I. General information

NPI: 1912243189
Provider Name (Legal Business Name): RALEIGH DURHAM MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 WEEKS DR
ROXBORO NC
27573-3933
US

IV. Provider business mailing address

5626 OBERLIN DR 110
SAN DIEGO CA
92121-1705
US

V. Phone/Fax

Practice location:
  • Phone: 336-598-5480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number104138
License Number StateNC

VIII. Authorized Official

Name: KENNY HEINE
Title or Position: VP OPS
Credential:
Phone: 858-964-1506