Provider Demographics
NPI:1174696363
Name:IDRISSI, RACHID (MD)
Entity type:Individual
Prefix:DR
First Name:RACHID
Middle Name:
Last Name:IDRISSI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:NC
Mailing Address - Zip Code:27504-1177
Mailing Address - Country:US
Mailing Address - Phone:919-894-1740
Mailing Address - Fax:919-894-2701
Practice Address - Street 1:1 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:NC
Practice Address - Zip Code:27504-1177
Practice Address - Country:US
Practice Address - Phone:919-894-1740
Practice Address - Fax:919-894-2701
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058038208100000X
NC2007005872081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909173Medicaid
NC5909173Medicaid