Provider Demographics
NPI:1972085918
Name:DYNAMIC HEALTH MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:DYNAMIC HEALTH MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:DIXIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WINSLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-525-6288
Mailing Address - Street 1:4705 SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217
Mailing Address - Country:US
Mailing Address - Phone:704-525-6288
Mailing Address - Fax:704-525-6384
Practice Address - Street 1:4705 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217
Practice Address - Country:US
Practice Address - Phone:704-525-6288
Practice Address - Fax:704-525-6384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNONE