Provider Demographics
NPI:1295706133
Name:SOUTHWEST DURHAM FAMILY MEDICINE, PLLC
Entity type:Organization
Organization Name:SOUTHWEST DURHAM FAMILY MEDICINE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-419-0242
Mailing Address - Street 1:1515 W NC HWY 54
Mailing Address - Street 2:STE 130
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707
Mailing Address - Country:US
Mailing Address - Phone:919-419-0242
Mailing Address - Fax:919-401-4172
Practice Address - Street 1:1515 W NC HWY 54
Practice Address - Street 2:STE 130
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707
Practice Address - Country:US
Practice Address - Phone:919-419-0242
Practice Address - Fax:919-401-4172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700021207R00000X
NC200300258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017RTOtherBLUE CROSS BLUE SHIELD
NC017RTOtherBLUE CROSS BLUE SHIELD