Basic Information
| Provider Information | |||||||||
| NPI: | 1619915501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RALEIGH FOOT CENTER,PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98209 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276248209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198509111 | ||||||||
| FaxNumber: | 9198502499 | ||||||||
| Practice Location | |||||||||
| Address1: | 1418 E MILLBROOK RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276094812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198509111 | ||||||||
| FaxNumber: | 9198502499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 02/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | HATCHER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9198509111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 89081E | 05 | NC | MEDICAID | 2431990A | 01 | NC | MEDICARE ID-PTAN | OTHER |