Healthcare Provider Details

I. General information

NPI: 1972085918
Provider Name (Legal Business Name): DYNAMIC HEALTH MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4705 SOUTH BLVD
CHARLOTTE NC
28217
US

IV. Provider business mailing address

4705 SOUTH BLVD
CHARLOTTE NC
28217
US

V. Phone/Fax

Practice location:
  • Phone: 704-525-6288
  • Fax: 704-525-6384
Mailing address:
  • Phone: 704-525-6288
  • Fax: 704-525-6384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DIXIE WINSLOW
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 704-525-6288