Provider Demographics
NPI:1548346331
Name:MED ONE MEDICAL GROUP
Entity type:Organization
Organization Name:MED ONE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE AND BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-850-1300
Mailing Address - Street 1:7019-200 HARPS MILL RD.
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615
Mailing Address - Country:US
Mailing Address - Phone:919-850-1300
Mailing Address - Fax:919-850-0012
Practice Address - Street 1:7019-200 HARPS MILL RD.
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615
Practice Address - Country:US
Practice Address - Phone:919-850-1300
Practice Address - Fax:919-850-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201835363LF0000X
NC2394111N00000X
NC930076207R00000X
NC0050-02018363LA2200X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5011967OtherLICENSE # - KERNEY YU
NC0010-04356OtherLICENSE # - TYLER CASSIDY
NC930076OtherCARA L. DAVIS LICENSE
NC2394OtherG. GRUBER DC LICENSE #
NC0050-02018OtherJ. CHARLES ANP LISCENSE
NC0050-02018OtherJ. CHARLES ANP LISCENSE
NCBD0613706OtherCARA L. DAVIS DEA #
NCMY5375147OtherDEA # - KERNEY YU
NC1558305060OtherG. GRUBER DC NPI
NCBD0613706OtherCARA L. DAVIS DEA #