Basic Information
| Provider Information | |||||||||
| NPI: | 1932661246 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RALEIGH DURHAM MEDICAL GROUP, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHPARK PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 63103 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282633103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192335956 | ||||||||
| FaxNumber: | 3123247850 | ||||||||
| Practice Location | |||||||||
| Address1: | 8300 HEALTH PARK STE 213 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276154731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198967066 | ||||||||
| FaxNumber: | 9198967067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2019 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | MOYE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9196140301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RALEIGH DURHAM MEDICAL GROUP PA | ||||||||
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| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.