Provider Demographics
NPI:1629716964
Name:NOVELLO SPECIALTY CLINIC PC
Entity Type:Organization
Organization Name:NOVELLO SPECIALTY CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-360-0183
Mailing Address - Street 1:4290 COPPER RIDGE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7208
Mailing Address - Country:US
Mailing Address - Phone:231-421-8505
Mailing Address - Fax:
Practice Address - Street 1:4100 PARK FOREST DR STE 200
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7306
Practice Address - Country:US
Practice Address - Phone:231-600-7466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-26
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty