Basic Information
| Provider Information | |||||||||
| NPI: | 1346264835 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVANT MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NOVANT HEALTH SLEEP MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043162050 | ||||||||
| FaxNumber: | 7043162051 | ||||||||
| Practice Location | |||||||||
| Address1: | 6909 PROSPERITY CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280786698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043162050 | ||||||||
| FaxNumber: | 7043162051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | SHALA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7043037517 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 017VP | 01 | NC | BCBS NC | OTHER | NPB162 | 05 | SC | MEDICAID | 1346264835 | 05 | NC | MEDICAID |