Provider Demographics
NPI:1679232417
Name:NOVANT MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC
Other - Org Name:NOVANT MEDICAL GROUP, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHALA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-303-7517
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:704-384-9437
Mailing Address - Fax:
Practice Address - Street 1:15033 BALLANCROFT PKWY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4958
Practice Address - Country:US
Practice Address - Phone:704-384-9437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-09
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty