Provider Demographics
NPI:1104012343
Name:RALEIGH DURHAM MEDICAL GROUP PA
Entity Type:Organization
Organization Name:RALEIGH DURHAM MEDICAL GROUP PA
Other - Org Name:ADVANCED SURGICAL ASSOCIATES
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 1:5420 WADE PARK BLVD
Mailing Address - Street 2:STE. 106
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-4188
Mailing Address - Country:US
Mailing Address - Phone:919-851-2174
Mailing Address - Fax:919-854-7774
Practice Address - Street 1:530 NEW WAVERLY PL
Practice Address - Street 2:STE. 304
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7414
Practice Address - Country:US
Practice Address - Phone:919-851-9193
Practice Address - Fax:919-851-9223
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RALEIGH DURHAM MEDICAL GROUP PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-21
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016W6OtherBCBS
NC5900017Medicaid