Provider Demographics
NPI:1417973298
Name:ALLEY, JOHN GRANVILLE JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GRANVILLE
Last Name:ALLEY
Suffix:JR
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 1:5220 GREENS DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-4612
Mailing Address - Country:US
Mailing Address - Phone:919-256-3576
Mailing Address - Fax:
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610
Practice Address - Country:US
Practice Address - Phone:919-350-7000
Practice Address - Fax:919-375-8959
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012704382085R0202X
NC99010972085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89036TCMedicaid
NC2026457Medicare PIN
I09696Medicare UPIN