MEDICARE: JAY GRAYSON FERNANDO MD

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	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician	9901172	NC
2	207R00000X	Internal Medicine Physician	9901172	NC
3	207RA0401X	Addiction Medicine (Internal Medicine) Physician	9901172	NC
4	174400000X	Specialist	9901172	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750337325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAY GRAYSON FERNANDO MD

Provider Business Mailing Address
First Line	:	7615 COLONY RD
Second Line	:	STE 115
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-5017
Country	:	US
Telephone Number	:	704-626-6812
Fax Number	:	704-626-6824

Provider Business Practice Location Address
First Line	:	7615 COLONY RD
Second Line	:	STE 115
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-5017
Country	:	US
Telephone Number	:	704-626-6812
Fax Number	:	704-626-6824

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	06/20/2024

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