MEDICARE: RECON NEUROLOGY & PSYCHIATRY

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	2084P0800X	Psychiatry Physician
2	2084N0400X	Neurology Physician

General Provider Information

NPI Number	:	1427769140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RECON NEUROLOGY & PSYCHIATRY

Provider Business Mailing Address
First Line	:	1340 WALTER REED RD STE 202
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-4451
Country	:	US
Telephone Number	:	910-504-3506
Fax Number	:	910-504-3507

Provider Business Practice Location Address
First Line	:	1340 WALTER REED RD STE 202
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-4451
Country	:	US
Telephone Number	:	910-504-3506
Fax Number	:	910-504-3507

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	LISA HUDSON
Credential	:
Telephone Number	:	910-372-6172

Provider Enumeration Date	:	12/13/2022
Last Update Date	:	01/13/2026

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