Provider Demographics
NPI:1598702490
Name:RALEIGH NEUROSURGICAL CLINIC, INC.
Entity Type:Organization
Organization Name:RALEIGH NEUROSURGICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:A
Authorized Official - Last Name:RODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-785-3400
Mailing Address - Street 1:PO BOX 63082
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3082
Mailing Address - Country:US
Mailing Address - Phone:919-785-3400
Mailing Address - Fax:919-783-7778
Practice Address - Street 1:5838 SIX FORKS RD STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-3893
Practice Address - Country:US
Practice Address - Phone:919-785-3400
Practice Address - Fax:919-783-7810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207T00000X
207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902497Medicaid
NC8902497Medicaid