Provider Demographics
NPI:1649342072
Name:NOVANT MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:704-384-9679
Mailing Address - Fax:704-316-0508
Practice Address - Street 1:710 SUNSET BLVD N
Practice Address - Street 2:SUITE B
Practice Address - City:SUNSET BEACH
Practice Address - State:NC
Practice Address - Zip Code:28468-4345
Practice Address - Country:US
Practice Address - Phone:910-575-0006
Practice Address - Fax:910-575-3972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC018PAOtherBCBS NC
NC5905835Medicaid
NC018PAOtherBCBS NC