Basic Information
| Provider Information | |||||||||
| NPI: | 1083885404 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RALEIGH DURHAM MEDICAL GROUP PA | ||||||||
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| OtherOrganizationName: | FOOTHILLS MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5420 WADE PARK BLVD | ||||||||
| Address2: | STE. 106 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276074188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198512174 | ||||||||
| FaxNumber: | 9198547774 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 W MILLS ST | ||||||||
| Address2: | STE. C | ||||||||
| City: | COLUMBUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287228494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288945627 | ||||||||
| FaxNumber: | 8288945879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 03/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | MOYE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9198512174 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RALEIGH DURHAM MEDICAL GROUP PA | ||||||||
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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 |
No ID Information.