1790725299 NPI number — NOVANT HEALTH MEDICAL GROUP, LLC

Table of content: (NPI 1790725299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790725299 NPI number — NOVANT HEALTH MEDICAL GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOVANT HEALTH MEDICAL GROUP, LLC
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:
1790725299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2024
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:
704-384-1440
Provider Business Mailing Address Fax Number:
704-384-1452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16139 LANCASTER HWY
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277-2033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-384-1440
Provider Business Practice Location Address Fax Number:
704-384-1452
Provider Enumeration Date:
06/07/2006

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: "Y" .

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

  • Identifier: 011JF . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: NPA897 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89011JF , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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