Basic Information
| Provider Information | |||||||||
| NPI: | 1356387245 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RALEIGH DURHAM MEDICAL GROUP PA | ||||||||
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| OtherOrganizationName: | TRINITY WOMEN'S HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 TRINITY RD | ||||||||
| Address2: | STE 105 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276076001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198512174 | ||||||||
| FaxNumber: | 9198547774 | ||||||||
| Practice Location | |||||||||
| Address1: | 7019 HARPS MILL RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276153248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198442226 | ||||||||
| FaxNumber: | 9198442219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOYE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9198512174 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 018E4 | 01 | NC | BCBS | OTHER | 5900258 | 05 | NC | MEDICAID |