Basic Information
| Provider Information | |||||||||
| NPI: | 1295006997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RALEIGH DURHAM MEDICAL GROUP, PA | ||||||||
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| OtherOrganizationName: | ROXBORO FAMILY MEDICINE & IMMEDIATE CARE | ||||||||
| 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: | 9192335952 | ||||||||
| FaxNumber: | 9198547774 | ||||||||
| Practice Location | |||||||||
| Address1: | 3762 DURHAM RD | ||||||||
| Address2: | |||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275732741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365985480 | ||||||||
| FaxNumber: | 3365985482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2012 | ||||||||
| LastUpdateDate: | 02/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | MOYE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| 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 | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.