=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871064949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK URGENT CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2018
-----------------------------------------------------
Last Update Date | 12/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7560 CARPENTER FIRE STATION RD
-----------------------------------------------------
City | CARY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27519-8616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-261-6677
-----------------------------------------------------
Fax | 919-261-6860
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2025 GIOVANNI CT
-----------------------------------------------------
City | CARY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27518-7106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-261-6677
-----------------------------------------------------
Fax | 919-261-6860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VIJAYA N POLAVARAM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 919-261-6677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------