Provider Demographics
NPI:1033160643
Name:RALEIGH DURHAM MEDICAL GROUP PA
Entity Type:Organization
Organization Name:RALEIGH DURHAM MEDICAL GROUP PA
Other - Org Name:CAROLINA FAMILY PRACTICE & SPORTS MEDICINE
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:919-851-2174
Mailing Address - Street 1:5400 TRINITY RD
Mailing Address - Street 2:STE 105
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6001
Mailing Address - Country:US
Mailing Address - Phone:919-851-2174
Mailing Address - Fax:919-854-7774
Practice Address - Street 1:3700 NW CARY PKWY
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-8422
Practice Address - Country:US
Practice Address - Phone:919-238-2000
Practice Address - Fax:919-238-5010
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:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC014RUOtherBCBS