Provider Demographics
NPI:1003301300
Name:AMITY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:AMITY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DEQUEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-493-5326
Mailing Address - Street 1:6010 E W T HARRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-4084
Mailing Address - Country:US
Mailing Address - Phone:704-208-4134
Mailing Address - Fax:704-248-8068
Practice Address - Street 1:6010 E W T HARRIS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-4084
Practice Address - Country:US
Practice Address - Phone:704-208-4134
Practice Address - Fax:704-248-8068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-28
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty