Healthcare Provider Details

I. General information

NPI: 1003301300
Provider Name (Legal Business Name): AMITY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6010 E W T HARRIS BLVD
CHARLOTTE NC
28215-4084
US

IV. Provider business mailing address

6010 E W T HARRIS BLVD
CHARLOTTE NC
28215-4084
US

V. Phone/Fax

Practice location:
  • Phone: 704-208-4134
  • Fax: 704-248-8068
Mailing address:
  • Phone: 704-208-4134
  • Fax: 704-248-8068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DEQUEENA SMITH
Title or Position: CREDENTIALING
Credential:
Phone: 704-493-5326