Provider Demographics
NPI:1821398744
Name:RALEIGH DURHAM MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:RALEIGH DURHAM MEDICAL GROUP, PA
Other - Org Name:COMMUNITY FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MOYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-851-2174
Mailing Address - Street 1:5420 WADE PARK BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-4188
Mailing Address - Country:US
Mailing Address - Phone:919-233-5952
Mailing Address - Fax:919-854-7774
Practice Address - Street 1:260 MERRIMON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-1274
Practice Address - Country:US
Practice Address - Phone:828-254-2444
Practice Address - Fax:828-254-0660
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RALEIGH DURHAM MEDICAL GROUP, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-26
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC023PFOtherBCBS
NC890153CMedicaid