Basic Information
Provider Information
NPI: 1104962315
EntityType: 2
ReplacementNPI:  
OrganizationName: RALEIGH MEDICAL GROUP, PA
LastName:  
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Mailing Information
Address1: PO BOX 18563
Address2:  
City: RALEIGH
State: NC
PostalCode: 276198563
CountryCode: US
TelephoneNumber: 9197821806
FaxNumber: 9197821669
Practice Location
Address1: 3521 HAWORTH DR
Address2:  
City: RALEIGH
State: NC
PostalCode: 276097216
CountryCode: US
TelephoneNumber: 9197821806
FaxNumber: 9197821669
Other Information
ProviderEnumerationDate: 01/29/2007
LastUpdateDate: 07/29/2021
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: COX
AuthorizedOfficialFirstName: CYNTHIA
AuthorizedOfficialMiddleName: R
AuthorizedOfficialTitleorPosition: ADMINISTRATOR
AuthorizedOfficialTelephone: 9193413618
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MRS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 07/29/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RG0100X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
207RH0003X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
207RR0500X  N193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
207R00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
0111201NCBCBSOTHER
890111205NC MEDICAID


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