Healthcare Provider Details

I. General information

NPI: 1205196037
Provider Name (Legal Business Name): COURTNEY GREGG SELF MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2012
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E MATTHEWS ST STE 100
MATTHEWS NC
28105
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-847-0572
  • Fax: 704-849-9760
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2017-02197
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: