Provider Demographics
NPI: | 1013419316 |
---|---|
Name: | NOVANT MEDICAL GROUP, INC. |
Entity Type: | Organization |
Organization Name: | NOVANT MEDICAL GROUP, INC. |
Other - Org Name: | NOVANT HEALTH WOUND CARE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | RCS MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | LEEA |
Authorized Official - Middle Name: | JEANINE |
Authorized Official - Last Name: | WALTON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 704-316-6081 |
Mailing Address - Street 1: | PO BOX 60447 |
Mailing Address - Street 2: | |
Mailing Address - City: | MATTHEWS |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28260-0447 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1450 MATTHEWS TOWNSHIP PARKWAY STE 280 |
Practice Address - Street 2: | |
Practice Address - City: | MATTHEWS |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28105-5331 |
Practice Address - Country: | US |
Practice Address - Phone: | 704-316-5166 |
Practice Address - Fax: | 704-316-5167 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-03-02 |
Last Update Date: | 2023-07-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |