Provider Demographics
NPI:1003868258
Name:RALEIGH DURHAM MEDICAL GROUP PA
Entity Type:Organization
Organization Name:RALEIGH DURHAM MEDICAL GROUP PA
Other - Org Name:WAVERLY PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:K
Authorized Official - Last Name:MOYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-614-0301
Mailing Address - Street 1:PO BOX 63103
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3103
Mailing Address - Country:US
Mailing Address - Phone:919-233-5952
Mailing Address - Fax:312-324-7850
Practice Address - Street 1:600 NEW WAVERLY PLACE
Practice Address - Street 2:STE 203
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518
Practice Address - Country:US
Practice Address - Phone:919-859-5650
Practice Address - Fax:919-859-5695
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RALEIGH DURHAM MEDICAL GROUP PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0231TOtherBCBS
NC5900362Medicaid