=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003301300
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMITY MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2018
-----------------------------------------------------
Last Update Date | 07/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6010 E W T HARRIS BLVD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-4084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-208-4134
-----------------------------------------------------
Fax | 704-248-8068
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6010 E W T HARRIS BLVD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-4084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-208-4134
-----------------------------------------------------
Fax | 704-248-8068
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | DEQUEENA SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-493-5326
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------