Basic Information
| Provider Information | |||||||||
| NPI: | 1306091939 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVANT MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | PRESBYTERIAN COSMETIC AND LASER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19620 W CATAWBA AVE | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | CORNELIUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280314052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043841775 | ||||||||
| FaxNumber: | 7043841776 | ||||||||
| Practice Location | |||||||||
| Address1: | 17810 STATESVILLE RD | ||||||||
| Address2: | SUITE 321 | ||||||||
| City: | CORNELIUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280318148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048955394 | ||||||||
| FaxNumber: | 7048955399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2008 | ||||||||
| LastUpdateDate: | 12/02/2008 | ||||||||
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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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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.