Provider Demographics
NPI:1508970278
Name:NOVANT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:WASSEL WOUND CARE
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 1:1900 RANDOLPH RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1122
Mailing Address - Country:US
Mailing Address - Phone:704-384-9113
Mailing Address - Fax:704-316-0508
Practice Address - Street 1:7752 GATEWAY LN
Practice Address - Street 2:SUITE 100
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-4418
Practice Address - Country:US
Practice Address - Phone:704-316-4950
Practice Address - Fax:704-316-4951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906340Medicaid
NC019FKOtherBCBS
NCK999OtherPARTNERS
NC019FKOtherBCBS