Provider Demographics
NPI:1467630202
Name:NOVANT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:SEASIDE ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DINESH
Authorized Official - Middle Name:S
Authorized Official - Last Name:PAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-384-9104
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:1733 SEASIDE ROAD SW
Practice Address - Street 2:SUITE C
Practice Address - City:OCEAN ISLE BEACH
Practice Address - State:NC
Practice Address - Zip Code:28469-5850
Practice Address - Country:US
Practice Address - Phone:910-575-9099
Practice Address - Fax:910-575-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31090207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5950408Medicaid
SC8625Medicare PIN
NC5950408Medicaid