Provider Demographics
NPI:1902170442
Name:RALEIGH CAPITOL EAR, NOSE, AND THROAT
Entity Type:Organization
Organization Name:RALEIGH CAPITOL EAR, NOSE, AND THROAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLARKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-787-7171
Mailing Address - Street 1:4600 LAKE BOONE TRL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7528
Mailing Address - Country:US
Mailing Address - Phone:919-787-1374
Mailing Address - Fax:919-420-2028
Practice Address - Street 1:4600 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7528
Practice Address - Country:US
Practice Address - Phone:919-787-1374
Practice Address - Fax:919-420-2028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPE-YPU8T38FAMedicaid