Provider Demographics
NPI:1063571040
Name:RALEIGH FAMILY PRACTICE PA
Entity type:Organization
Organization Name:RALEIGH FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-875-0539
Mailing Address - Street 1:4414 LAKE BOONE TRL
Mailing Address - Street 2:SUITE 502
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7513
Mailing Address - Country:US
Mailing Address - Phone:919-875-0539
Mailing Address - Fax:919-875-1051
Practice Address - Street 1:4414 LAKE BOONE TRL
Practice Address - Street 2:SUITE 502
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7513
Practice Address - Country:US
Practice Address - Phone:919-875-0539
Practice Address - Fax:919-875-1051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC84061207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7901842Medicaid
NC2327132Medicare ID - Type Unspecified