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General NPI Number Information
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NPI Number | 1497520654
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Entity Type | Organization
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Legal Business Name | PROVIDER HEALTH ALLIANCE
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Dates
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Enumeration Date | 11/17/2023
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Last Update Date | 11/17/2023
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Provider Practice Location Address
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Address Line | 1004 DRESSER CT STE 102
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City | RALEIGH
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State | NC
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Zip | 27609-7325
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Country | US
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Telephone | 919-654-7309
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Fax |
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Provider Business Mailing Address
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Address Line | 1004 DRESSER CT STE 102
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City | RALEIGH
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State | NC
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Zip | 27609-7325
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Country | US
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Telephone | 919-654-7309
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Fax |
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Authorized Official
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Title or Position | QUALITY / COMPLIANCE MANAGER
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Name | SHARON MENDENHALL
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Credential |
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Telephone | 919-654-7309
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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