Basic Information
| Provider Information | |||||||||
| NPI: | 1316082357 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RALEIGH DURHAM MEDICAL GROUP PA | ||||||||
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| OtherOrganizationName: | CAROLINA CARDIOVASCULAR HEALTH & FITNESS | ||||||||
| 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: | 3100 DURALEIGH RD | ||||||||
| Address2: | STE 307 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276128106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192320050 | ||||||||
| FaxNumber: | 9192320060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 03/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | MOYE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VP | ||||||||
| 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 | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 144TM | 01 | NC | BCBS | OTHER | 891137F | 05 | NC | MEDICAID |