Provider Demographics
NPI:1902840762
Name:RALEIGH ADULT MEDICINE PA
Entity Type:Organization
Organization Name:RALEIGH ADULT MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-781-9979
Mailing Address - Street 1:3200 BLUE RIDGE RD
Mailing Address - Street 2:STE 210
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-8086
Mailing Address - Country:US
Mailing Address - Phone:919-781-9979
Mailing Address - Fax:919-781-0124
Practice Address - Street 1:3200 BLUE RIDGE RD
Practice Address - Street 2:STE 210
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8086
Practice Address - Country:US
Practice Address - Phone:919-781-9979
Practice Address - Fax:919-781-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02360OtherBCBS NC GROUP NUMBER
NC5902360Medicaid
NC2344518Medicare ID - Type Unspecified