MEDICARE: AMITY MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1003301300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMITY MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	6010 E W T HARRIS BLVD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-4084
Country	:	US
Telephone Number	:	704-208-4134
Fax Number	:	704-248-8068

Provider Business Practice Location Address
First Line	:	6010 E W T HARRIS BLVD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-4084
Country	:	US
Telephone Number	:	704-208-4134
Fax Number	:	704-248-8068

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	DEQUEENA SMITH
Credential	:
Telephone Number	:	704-493-5326

Provider Enumeration Date	:	06/28/2018
Last Update Date	:	07/31/2024

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Directions to “AMITY MEDICAL GROUP, INC. ” Practice Location

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