Provider Demographics
NPI:1437463130
Name:RALEIGH DURHAM MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:RALEIGH DURHAM MEDICAL GROUP, PA
Other - Org Name:DURHAM FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
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:919-614-0301
Mailing Address - Street 1:PO BOX 63103
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3103
Mailing Address - Country:US
Mailing Address - Phone:919-233-5952
Mailing Address - Fax:312-324-7850
Practice Address - Street 1:2400 BROAD ST
Practice Address - Street 2:STE 1
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2661
Practice Address - Country:US
Practice Address - Phone:919-220-9800
Practice Address - Fax:919-220-9500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RALEIGH DURHAM MEDICAL GROUP, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-05
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5915531Medicaid
NC023N5OtherBCBS