Basic Information
| Provider Information | |||||||||
| NPI: | 1417907544 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RALEIGH DURHAM MEDICAL GROUP PA | ||||||||
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| OtherOrganizationName: | ALLIANCE FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5420 WADE PARK BLVD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276074188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192335952 | ||||||||
| FaxNumber: | 9198547774 | ||||||||
| Practice Location | |||||||||
| Address1: | 4505 FAIR MEADOWS LN | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276076465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197839600 | ||||||||
| FaxNumber: | 9197839675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | MOYE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9198512174 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RALEIGH DURHAM MEDICAL GROUP PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5900354 | 05 | NC | MEDICAID | 0234V | 01 | NC | BCBS | OTHER |