Provider Demographics
NPI:1477609535
Name:PRIVATE DIAGNOSTIC CLINIC, PLLC
Entity type:Organization
Organization Name:PRIVATE DIAGNOSTIC CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:10441 MONCREIFFE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-7810
Practice Address - Country:US
Practice Address - Phone:800-266-3853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207RG0100X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2380017Medicare PIN