Healthcare Provider Details

I. General information

NPI: 1306906086
Provider Name (Legal Business Name): PAYTON GREGORY FENNELL D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4741 RANDOLPH RD
CHARLOTTE NC
28211-2919
US

IV. Provider business mailing address

52 12TH AVE NE
HICKORY NC
28601-2798
US

V. Phone/Fax

Practice location:
  • Phone: 704-365-6730
  • Fax: 704-365-6731
Mailing address:
  • Phone: 828-485-3004
  • Fax: 828-328-4049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200601317
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number200601317
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: