Basic Information
| Provider Information | |||||||||
| NPI: | 1164559795 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIME MEDICAL ASSOCIATES OF NORTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH RALEIGH INTERNAL MEDICINE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99279 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276249279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198031417 | ||||||||
| FaxNumber: | 9198031418 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 REXWOODS DR | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276073366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198031417 | ||||||||
| FaxNumber: | 9198031418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 01/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | YACONO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | V. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9198767200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 96-01110 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0286L | 01 | NC | BLUE CROSS BLUE SHIELD NC | OTHER |