=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598293714
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC PHYSIATRY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2017
-----------------------------------------------------
Last Update Date | 10/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2015 AYRSLEY TOWN BLVD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28273-4067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-609-0499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2015 AYRSLEY TOWN BLVD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28273-4067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-609-0499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | JOANNE OTEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-609-0499
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 2008-00366
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------