1235458985 NPI number — NOVANT MEDICAL GROUP, INC

Table of content: (NPI 1235458985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235458985 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 PRIMARY CARE PARTNERS
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:
1235458985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2023
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:
919-570-5705
Provider Business Mailing Address Fax Number:
919-570-5710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10500 LIGON MILL RD
Provider Second Line Business Practice Location Address:
SUITE 113
Provider Business Practice Location Address City Name:
WAKE FOREST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27587-4576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-570-5705
Provider Business Practice Location Address Fax Number:
919-570-5710
Provider Enumeration Date:
05/20/2010

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: 207Q00000X , with the licence number:  2005-01578 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5914970 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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