Provider Demographics
NPI:1457311870
Name:MID-CAROLINA OB/GYN
Entity Type:Organization
Organization Name:MID-CAROLINA OB/GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:F
Authorized Official - Last Name:WOODRUFF
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:919-781-5510
Mailing Address - Street 1:4414 LAKE BOONE TRL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7513
Mailing Address - Country:US
Mailing Address - Phone:919-781-5510
Mailing Address - Fax:919-781-5053
Practice Address - Street 1:4414 LAKE BOONE TRL
Practice Address - Street 2:SUITE 300
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7513
Practice Address - Country:US
Practice Address - Phone:919-781-5510
Practice Address - Fax:919-781-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890161YMedicaid
NC0161YOtherBC/BS
NC890161YMedicaid
NC0349Medicare ID - Type Unspecified