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	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	230581	OTHER	NC	MCA GRP. #

General Provider Information

NPI Number	:	1659563377
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	:	4309 MEDICAL PARK DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-2388
Country	:	US
Telephone Number	:	919-471-9622
Fax Number	:

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

Provider Enumeration Date	:	08/16/2007
Last Update Date	:	07/11/2022

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