Provider Demographics
NPI:1477520088
Name:CAROLINA SPECIALTY ONCOLOGY, PA
Entity Type:Organization
Organization Name:CAROLINA SPECIALTY ONCOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:KHOUDARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-334-3900
Mailing Address - Street 1:117 SUNNYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1827
Mailing Address - Country:US
Mailing Address - Phone:919-334-3910
Mailing Address - Fax:919-250-9280
Practice Address - Street 1:117 SUNNYBROOK RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1827
Practice Address - Country:US
Practice Address - Phone:919-334-3910
Practice Address - Fax:919-250-9280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-02
Last Update Date:2015-12-09
Deactivation Date:2006-03-02
Deactivation Code:
Reactivation Date:2006-03-07
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5922273Medicaid
NC01708OtherBCBS
NC01708OtherBCBS