Provider Demographics
NPI:1952385767
Name:REGIONAL SURGICAL ASSOCIATES PA
Entity type:Organization
Organization Name:REGIONAL SURGICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF THE BOARD
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHADDUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-479-4400
Mailing Address - Street 1:PO BOX 15698
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704
Mailing Address - Country:US
Mailing Address - Phone:919-479-4400
Mailing Address - Fax:919-479-4415
Practice Address - Street 1:4301 BEN FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704
Practice Address - Country:US
Practice Address - Phone:919-479-4400
Practice Address - Fax:919-479-4415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0261EOtherBCBSNC
NC890261EMedicaid
NC0261EOtherBCBSNC