1295916203 NPI number — NOVANT MEDICAL GROUP, INC.

Table of content: (NPI 1295916203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295916203 NPI number — NOVANT MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOVANT MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NOVANT HEALTH DURHAM INTERNAL MEDICINE ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295916203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-477-6900
Provider Business Mailing Address Fax Number:
919-477-5081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4205 BEN FRANKLIN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27704-2143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-477-6900
Provider Business Practice Location Address Fax Number:
919-477-5081
Provider Enumeration Date:
11/19/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
SHALA
Authorized Official Middle Name:
Authorized Official Title or Position:
RCS MGR
Authorized Official Telephone Number:
704-303-7517

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 019NV . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: K414 . This is a "BLUE MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: DG6234 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5908373 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".