Basic Information
| Provider Information | |||||||||
| NPI: | 1437140647 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVA NEUROSURGICAL, P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4428 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274044428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362724578 | ||||||||
| FaxNumber: | 3362725931 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 N CHURCH ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362724578 | ||||||||
| FaxNumber: | 3362725931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3362724578 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 8902400 | 05 | NC | MEDICAID | 02400 | 01 | NC | BLUE CROSS | OTHER |