Basic Information
Provider Information | |||||||||
NPI: | 1104012343 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RALEIGH DURHAM MEDICAL GROUP PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADVANCED SURGICAL ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 530 NEW WAVERLY PL | ||||||||
Address2: | STE. 304 | ||||||||
City: | CARY | ||||||||
State: | NC | ||||||||
PostalCode: | 275187414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9198519193 | ||||||||
FaxNumber: | 9198519223 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2007 | ||||||||
LastUpdateDate: | 03/05/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOYE | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9198512174 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | RALEIGH DURHAM MEDICAL GROUP PA | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 016W6 | 01 | NC | BCBS | OTHER | 5900017 | 05 | NC |   | MEDICAID |