Basic Information
| Provider Information | |||||||||
| NPI: | 1154364172 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVANT MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | PRESBYTERIAN NEWBORN SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 RANDOLPH RD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043849113 | ||||||||
| FaxNumber: | 7043160508 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HAWTHORNE LN | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043846296 | ||||||||
| FaxNumber: | 7043846533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | PAI | ||||||||
| AuthorizedOfficialFirstName: | DINESH | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7043849104 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5900494 | 05 | NC | MEDICAID | NPB140 | 05 | SC | MEDICAID |