Basic Information
| Provider Information | |||||||||
| NPI: | 1447306113 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIVATE DIAGNOSTIC CLINIC, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEDIATRIC PRIMARY CARE CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 110566 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277095566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196204855 | ||||||||
| FaxNumber: | 9196204921 | ||||||||
| Practice Location | |||||||||
| Address1: | 4020 N ROXBORO ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196848111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | NEWMAN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9196204855 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | NC | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 251S00000X | N | Agencies | Community/Behavioral Health | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.