Healthcare Provider Details

I. General information

NPI: 1417446691
Provider Name (Legal Business Name): MECKLENBURG NEUROLOGY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 LAKE CONCORD RD NE
CONCORD NC
28025-3057
US

IV. Provider business mailing address

70 LAKE CONCORD RD NE
CONCORD NC
28025-3057
US

V. Phone/Fax

Practice location:
  • Phone: 980-777-8311
  • Fax: 980-777-8274
Mailing address:
  • Phone: 980-777-8311
  • Fax: 980-777-8274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number9400705
License Number StateNC

VIII. Authorized Official

Name: MICHAEL M AMIRI
Title or Position: OWNER
Credential: MD
Phone: 704-335-9794