MEDICARE: PRIVATE DIAGNOSTIC CLINIC, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician

General Provider Information

NPI Number	:	1306879390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIVATE DIAGNOSTIC CLINIC, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 110566
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27709-5566
Country	:	US
Telephone Number	:	919-620-4855
Fax Number	:	919-620-4921

Provider Business Practice Location Address
First Line	:	11618 US HIGHWAY 70 W
Second Line	:	SUITE 200B
City	:	CLAYTON
State	:	NC
Zip	:	27520-2253
Country	:	US
Telephone Number	:	919-684-8111
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	CHRISTOPHER THOMAS FREDERICK
Credential	:
Telephone Number	:	919-613-7762

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	05/15/2022

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