Provider Demographics
NPI:1821151069
Name:RALLIS, MICHAEL GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GEORGE
Last Name:RALLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1179
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-1179
Mailing Address - Country:US
Mailing Address - Phone:910-259-5011
Mailing Address - Fax:
Practice Address - Street 1:2778 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-8028
Practice Address - Country:US
Practice Address - Phone:910-259-5011
Practice Address - Fax:910-259-3060
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23750207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8969959Medicaid
NC69959OtherBCBS
NC409113857OtherRAILROAD MEDICARE
NC202313CMedicare ID - Type Unspecified
NCC81196Medicare UPIN