1104152024 NPI number — NOVANT MEDICAL GROUP INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104152024 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:
Provider Other Organization Name Type Code:
6
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:
1104152024
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2023
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:
704-279-1679
Provider Business Mailing Address Fax Number:
704-279-1677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 S SALISBURY GQ AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALISBURY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28146-8150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-279-1679
Provider Business Practice Location Address Fax Number:
704-279-1677
Provider Enumeration Date:
10/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WALTON
Authorized Official First Name:
LEEA
Authorized Official Middle Name:
JEANINE
Authorized Official Title or Position:
RCS MANAGER
Authorized Official Telephone Number:
704-316-6081

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5913612 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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