=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548346331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MED ONE MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7019-200 HARPS MILL RD.
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-850-1300
-----------------------------------------------------
Fax | 919-850-0012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7019-200 HARPS MILL RD.
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-850-1300
-----------------------------------------------------
Fax | 919-850-0012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE AND BILLING MANAGER
-----------------------------------------------------
Name | MS. TIFFANY L. CONNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-850-1300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 201835
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2394
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 930076
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 0050-02018
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------