Provider Demographics
NPI:1275759581
Name:THERTULIEN, RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:
Last Name:THERTULIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 QUEENS RD STE 610
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3580
Practice Address - Country:US
Practice Address - Phone:980-302-6600
Practice Address - Fax:980-302-6605
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00361207R00000X, 207RH0003X, 207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP01028293OtherRAILROAD MEDICARE
NC7964243OtherAETNA
AR143705001Medicaid
NC5906570Medicaid
NC4510132OtherCIGNA
NCNC4876BMedicare PIN
NC5906570Medicaid
ARH 38237Medicare UPIN
AR143705001Medicaid