Basic Information
| Provider Information | |||||||||
| NPI: | 1275023384 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVANT HEALTH | ||||||||
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| OtherOrganizationName: | NOVANT HEALTH URGENT CARE & OCCUPATIONAL MEDICINE- KERNERSVILLE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3233 SPARROWHAWK DR | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272659548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366884929 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 GATEWAY CENTER DR | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272842999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369962173 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HUTSON | ||||||||
| AuthorizedOfficialFirstName: | JEREMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SUPERVISING PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3369962173 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.