Provider Demographics
NPI:1679378897
Name:RALEIGH DURHAM MEDICAL GROUP PA
Entity type:Organization
Organization Name:RALEIGH DURHAM MEDICAL GROUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOWIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-580-3236
Mailing Address - Street 1:PO BOX 96860
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28296-6860
Mailing Address - Country:US
Mailing Address - Phone:919-520-3236
Mailing Address - Fax:919-854-7774
Practice Address - Street 1:3818 N ELM ST STE E
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2778
Practice Address - Country:US
Practice Address - Phone:336-686-5298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-13
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty