Basic Information
| Provider Information | |||||||||
| NPI: | 1215517735 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVANT HEALTH MEDICAL GROUP COASTAL REGION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 936857 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311936857 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2259 S 17TH ST | ||||||||
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| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106629300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2021 | ||||||||
| LastUpdateDate: | 04/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | SHALA | ||||||||
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| AuthorizedOfficialTitleorPosition: | RCS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7043167845 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.