Provider Demographics
NPI:1043486483
Name:NOVANT MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RCS MGR
Authorized Official - Prefix:
Authorized Official - First Name:SHALA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-303-7517
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:919-477-6900
Mailing Address - Fax:919-544-6210
Practice Address - Street 1:5107 SOUTHPARK DR
Practice Address - Street 2:SUITE 104
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-8400
Practice Address - Country:US
Practice Address - Phone:919-477-6900
Practice Address - Fax:919-544-6210
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOVANT MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-06
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908373Medicaid
NC5908373Medicaid