Basic Information
| Provider Information | |||||||||
| NPI: | 1649342072 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVANT MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | SUNSET BEACH FAMILY MEDICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043849679 | ||||||||
| FaxNumber: | 7043160508 | ||||||||
| Practice Location | |||||||||
| Address1: | 710 SUNSET BLVD N | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SUNSET BEACH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284684345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105750006 | ||||||||
| FaxNumber: | 9105753972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 02/11/2009 | ||||||||
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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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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 018PA | 01 | NC | BCBS NC | OTHER | 5905835 | 05 | NC | MEDICAID |