Provider Demographics
NPI:1477099471
Name:PRIVATE DIAGNOSITC CLINIC
Entity Type:Organization
Organization Name:PRIVATE DIAGNOSITC CLINIC
Other - Org Name:DUKE CHILDREN'S PRIMARY CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VICE DEAN ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-684-3945
Mailing Address - Street 1:PO BOX 110566
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27709-5566
Mailing Address - Country:US
Mailing Address - Phone:919-620-4855
Mailing Address - Fax:919-307-0323
Practice Address - Street 1:10211 ALM ST
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-8221
Practice Address - Country:US
Practice Address - Phone:919-307-0301
Practice Address - Fax:919-307-0323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-13
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC561029437261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1447306113Medicaid