Basic Information
| Provider Information | |||||||||
| NPI: | 1083666887 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVANT MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | NOVANT HEALTH NEUROLOGY AND SLEEP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043849437 | ||||||||
| FaxNumber: | 7043849440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1918 RANDOLPH RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043849437 | ||||||||
| FaxNumber: | 7043849440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | SHALA | ||||||||
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| AuthorizedOfficialTitleorPosition: | RCS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7043037517 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 5903547 | 05 | NC | MEDICAID | CC5118 | 01 | NC | RAILROAD MEDICARE | OTHER | NPB172 | 05 | SC | MEDICAID | 017YG | 01 | NC | BCBS NC | OTHER |