=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124501085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELECT MEDICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2018
-----------------------------------------------------
Last Update Date | 03/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10931 RAVEN RIDGE RD STE 115
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27614-6499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-676-0202
-----------------------------------------------------
Fax | 919-676-0224
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10931 RAVEN RIDGE RD STE 115
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27614-6499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-801-5142
-----------------------------------------------------
Fax | 919-589-7749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JENNIFER C ARATA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-676-0202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 243501
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------