Provider Demographics
NPI:1427056027
Name:D MICHAEL MAHAN MD PA
Entity type:Organization
Organization Name:D MICHAEL MAHAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-693-7108
Mailing Address - Street 1:120 CHARLES D ROLLINS RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2882
Mailing Address - Country:US
Mailing Address - Phone:252-436-6543
Mailing Address - Fax:252-436-2109
Practice Address - Street 1:120 CHARLES D ROLLINS RD
Practice Address - Street 2:SUITE 105
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2882
Practice Address - Country:US
Practice Address - Phone:252-436-6543
Practice Address - Fax:252-436-2109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25053207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC012JGOtherBCBSNC
NC89012JGMedicaid
NCD3535Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NC89012JGMedicaid
NCC89071Medicare UPIN