=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225090772
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TEDRIC DALE BOYSE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 WIND CHIME CT
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27615-6433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-847-6431
-----------------------------------------------------
Fax | 919-847-7005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 WIND CHIME CT
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27615-6433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-847-6431
-----------------------------------------------------
Fax | 919-847-7005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------