Basic Information
| Provider Information | |||||||||
| NPI: | 1033160627 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RALEIGH DURHAM MEDICAL GROUP PA | ||||||||
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| OtherOrganizationName: | CARRBORO FAMILY MEDICINE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 TRINITY RD | ||||||||
| Address2: | STE 105 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276076001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198512174 | ||||||||
| FaxNumber: | 9198547774 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 JONES FERRY RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | CARRBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275106113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199291747 | ||||||||
| FaxNumber: | 9199294862 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOYE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9198512174 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 890116E | 05 | NC | MEDICAID | 0116E | 01 | NC | BCBS | OTHER |