| Amity Medical Group, Inc. | |
|
6010 E W T Harris Blvd Charlotte NC 28215-4084 | |
| (704) 208-4134 | |
| (704) 248-8068 |
| Full Name | Amity Medical Group, Inc. |
|---|---|
| Speciality | Clinic/Center |
| Location | 6010 E W T Harris Blvd, Charlotte, North Carolina |
| Authorized Official Name and Position | Dequeena Smith (CREDENTIALING) |
| Authorized Official Contact | 7044935326 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Amity Medical Group, Inc. 6010 E W T Harris Blvd Charlotte NC 28215-4084 Ph: (704) 208-4134 | Amity Medical Group, Inc. 6010 E W T Harris Blvd Charlotte NC 28215-4084 Ph: (704) 208-4134 |
| NPI Number | 1003301300 |
|---|---|
| Provider Enumeration Date | 06/28/2018 |
| Last Update Date | 07/31/2024 |
| Medicare PECOS PAC ID | 7618205980 |
|---|---|
| Medicare Enrollment ID | O20190823002238 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1003301300 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Secondary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
| Provider Name | Karlton Shea Pettis |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1871555375 PECOS PAC ID: 0143208447 Enrollment ID: I20040713000257 |
| Provider Name | Richard T Wynn |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1356365480 PECOS PAC ID: 5890764419 Enrollment ID: I20040930000417 |
| Provider Name | Renae M Walton |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1639378706 PECOS PAC ID: 1951470624 Enrollment ID: I20080725000413 |
| Provider Name | Heather M Manos |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1427186022 PECOS PAC ID: 7315082161 Enrollment ID: I20110120000363 |
| Provider Name | Clarence O Neil Ellis |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1376505305 PECOS PAC ID: 7719870146 Enrollment ID: I20110817000525 |
| Provider Name | Sarah Lynn Helms |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1083964290 PECOS PAC ID: 9436394335 Enrollment ID: I20130326000000 |
| Provider Name | Jerry Allen Saunders |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1306137526 PECOS PAC ID: 7012226947 Enrollment ID: I20151015002229 |
| Provider Name | Jason Lamarr Hardin |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1932675758 PECOS PAC ID: 2264762012 Enrollment ID: I20190923000809 |
| Provider Name | Raymond Castillo |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1457940165 PECOS PAC ID: 1153707856 Enrollment ID: I20240410002599 |
| Provider Name | Michelle Clanton |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1295403368 PECOS PAC ID: 9133569569 Enrollment ID: I20240501003365 |
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