Provider Demographics
NPI: | 1972881506 |
---|---|
Name: | PRIVATE DIAGNOSTIC CLINIC, PLLC |
Entity Type: | Organization |
Organization Name: | PRIVATE DIAGNOSTIC CLINIC, PLLC |
Other - Org Name: | BURLINGTON MEDICAL PRACTICE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | CFO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CHRISTOPHER |
Authorized Official - Middle Name: | THOMAS |
Authorized Official - Last Name: | FREDERICK |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 919-613-7762 |
Mailing Address - Street 1: | PO BOX 110566 |
Mailing Address - Street 2: | |
Mailing Address - City: | DURHAM |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 27709-5566 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 919-620-4855 |
Mailing Address - Fax: | 919-620-4921 |
Practice Address - Street 1: | 1248 HUFFMAN MILL RD |
Practice Address - Street 2: | STE. 103 |
Practice Address - City: | BURLINGTON |
Practice Address - State: | NC |
Practice Address - Zip Code: | 27215-8700 |
Practice Address - Country: | US |
Practice Address - Phone: | 336-584-5200 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-08-01 |
Last Update Date: | 2022-07-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty |