Provider Demographics
NPI:1497520654
Name:PROVIDER HEALTH ALLIANCE
Entity Type:Organization
Organization Name:PROVIDER HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QUALITY / COMPLIANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDENHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-654-7309
Mailing Address - Street 1:1004 DRESSER CT STE 102
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7325
Mailing Address - Country:US
Mailing Address - Phone:919-654-7309
Mailing Address - Fax:
Practice Address - Street 1:1004 DRESSER CT STE 102
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7325
Practice Address - Country:US
Practice Address - Phone:919-654-7309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty