NPIMap

Individual provider Active NPI

Gregory Derrick Tallent, PAC

  • Physician Assistant
  • Raleigh, NC
National Provider Identifier
1982716585
Registry record updated Nov 23, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
0010-00359 Issued in NC
Practice address
4420 Lake Boone TRL
Raleigh, NC 27607-7505
Phone
(919) 784-3100
NPI assigned
Aug 31, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 23, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 021664 NY
Medical Physician Assistant 363AM0700X 1020 SC
Medical Physician Assistant 363AM0700X 001000359 NC
Physician Assistant 363A00000X 0010-00359 NC Primary

Addresses

Primary practice location

4420 Lake Boone TRL
Raleigh, NC 27607-7505

Mailing address

2500 Blue Ridge Rd Ste 417
Raleigh, NC 27607-7516
Phone (919) 787-9097

Other practice location 1

809 82nd Pkwy
Myrtle Beach, SC 29572-4607
Phone (843) 497-5929

Other identifiers 5

IdentifierTypeStateIssuer
GP1062MedicaidSC
02914OtherNCNC BCBS
1020OtherSCMEDICAL LICENSE
8902914MedicaidNC
CM7718OtherRAILROAD MEDICARE

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address gtallent515210@direct.UNC.nchie.net Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC, NC, NY3 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
I20050623000702 SC Practitioner - Physician Assistant 5395780977 Reassigns benefits to 3 organizations
I20101130000932 NC Practitioner - Physician Assistant 5395780977 Reassigns benefits to 5 organizations
I20180112002606 NY Practitioner - Physician Assistant 5395780977 Reassigns benefits to 3 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2005
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Certus Psychiatry and Integrated Care PLLCGroup PAC ID 0244506756, 17 clinicians

Practice addresses (Care Compare)

1255 Creekshire Way
Suite 270
Winston Salem, NC 27103-3061
Phone (336) 701-3111

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
021664NYMDPsychologist
001000359NCMDMedical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Thrive Essential Wellness, Inc. Medical Current Accepting new patients
Gastonia Physician Services, PLLC CurrentSince Apr 20, 2016 Accepting new patients
Rex Hospital Inc Past Accepting new patients
Marion SC Emergency Physicians Past Accepting new patients
Southern Living Emergency Physicians LLC Physician Assistant Past Accepting new patients

Locations

2525 Court Dr
Gastonia, NC 28054
Phone (704) 834-2662

Interoperability endpoints

  • Direct secure messaging: gtallent515210@direct.unc.nchie.net

Organizations & group practices 16

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156982400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1637625600000",
    "number": "1982716585",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2500 BLUE RIDGE RD STE 417",
            "city": "RALEIGH",
            "state": "NC",
            "postal_code": "276077516",
            "telephone_number": "919-787-9097"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4420 LAKE BOONE TRL",
            "city": "RALEIGH",
            "state": "NC",
            "postal_code": "276077505",
            "telephone_number": "919-784-3100"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "809 82nd Pkwy",
            "address_purpose": "LOCATION",
            "city": "Myrtle Beach",
            "state": "SC",
            "postal_code": "295724607",
            "country_code": "US",
            "telephone_number": "843-497-5929",
            "fax_number": "843-497-6601",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "TALLENT",
        "first_name": "GREGORY",
        "middle_name": "DERRICK",
        "credential": "PAC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-08-31",
        "last_updated": "2021-11-23",
        "certification_date": "2021-03-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NY",
            "license": "021664",
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "SC",
            "license": "1020",
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "NC",
            "license": "001000359",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "0010-00359",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "GP1062",
            "state": "SC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NC BCBS",
            "identifier": "02914",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICAL LICENSE",
            "identifier": "1020",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8902914",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "CM7718",
            "state": null
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "gtallent515210@direct.UNC.nchie.net",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CDA/CCD/TXT",
            "address_1": "2500 Blue Ridge Rd Ste 417",
            "city": "Raleigh",
            "state": "NC",
            "country_code": "US",
            "postal_code": "276077516",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Raleigh, NC

Sources for this page

Verify at the official NPI Registry.