Provider Demographics
NPI:1720329261
Name:PRIVATE DIAGNOSTIC CLINIC, PLLC
Entity Type:Organization
Organization Name:PRIVATE DIAGNOSTIC CLINIC, PLLC
Other - Org Name:KERNODLE CLINIC-EASTTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, PDC
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-613-7652
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 1:316 N GRAHAM HOPEDALE RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-2969
Practice Address - Country:US
Practice Address - Phone:336-226-7384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-08
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty