Provider Demographics
NPI:1447306113
Name:PRIVATE DIAGNOSTIC CLINIC, PLLC
Entity type:Organization
Organization Name:PRIVATE DIAGNOSTIC CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-620-4855
Mailing Address - Street 1:PO BOX 110566
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27709-5566
Mailing Address - Country:US
Mailing Address - Phone:919-620-4855
Mailing Address - Fax:919-620-4921
Practice Address - Street 1:4020 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2120
Practice Address - Country:US
Practice Address - Phone:919-684-8111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208000000X
208000000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC230575Medicare PIN
NCCA4934Medicare PIN
NC1405Medicare PIN
NC2053888Medicare PIN
NC230587Medicare PIN
NC2310523CMedicare PIN
NC2325336Medicare PIN