Provider Demographics
NPI:1033218045
Name:AVALON MEDICAL GROUP
Entity Type:Organization
Organization Name:AVALON MEDICAL GROUP
Other - Org Name:AVALON INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:DILALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-928-1146
Mailing Address - Street 1:101 CONNER DR
Mailing Address - Street 2:STE 402
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-7038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 CONNER DR
Practice Address - Street 2:STE 402
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-7038
Practice Address - Country:US
Practice Address - Phone:919-928-1146
Practice Address - Fax:919-928-1148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700235207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC011P2OtherBC/BS
NC89011P2Medicaid
NC011P2OtherBC/BS