MEDICARE: MECKLENBURG MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207R00000X	Internal Medicine Physician
2	207RB0002X	Obesity Medicine (Internal Medicine) Physician
3	207RC0000X	Cardiovascular Disease Physician
4	207RE0101X	Endocrinology, Diabetes & Metabolism Physician
5	207RG0100X	Gastroenterology Physician
6	207RG0300X	Geriatric Medicine (Internal Medicine) Physician
7	207RH0003X	Hematology & Oncology Physician
8	207RI0200X	Infectious Disease Physician
9	207RP1001X	Pulmonary Disease Physician
10	207RR0500X	Rheumatology Physician
11	207RS0012X	Sleep Medicine (Internal Medicine) Physician
12	207RX0202X	Medical Oncology Physician
13	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1962728923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MECKLENBURG MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 19305
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28219-9305
Country	:	US
Telephone Number	:	704-631-0002
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 S COLLEGE ST
Second Line	:	STE 500
City	:	CHARLOTTE
State	:	NC
Zip	:	28202-2012
Country	:	US
Telephone Number	:	704-302-8800
Fax Number	:

Authorized Official
Title or Position	:	ENTERPRISE EVP
Name	:	SCOTT RISSMILLER
Credential	:
Telephone Number	:	704-355-8675

Provider Enumeration Date	:	04/15/2010
Last Update Date	:	03/09/2023

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Directions to “MECKLENBURG MEDICAL GROUP ” Practice Location

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