Provider Demographics
NPI:1740236702
Name:NOVANT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:NOVANT HEALTH COTSWOLD MEDICAL CLINIC
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:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7603
Mailing Address - Fax:704-417-4479
Practice Address - Street 1:200 GREENWICH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2316
Practice Address - Country:US
Practice Address - Phone:704-384-8680
Practice Address - Fax:704-384-8684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890271VMedicaid
NC0271VOtherBCBS-NC
NCCC5118OtherRAILROAD MEDICARE
NC2319872EMedicare PIN