Basic Information
| Provider Information | |||||||||
| NPI: | 1770964660 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVANT MEDICAL GROUP, INC | ||||||||
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| OtherOrganizationName: | NOVANT HEALTH PEDIATRICS SOUTH END | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043847606 | ||||||||
| FaxNumber: | 3362777722 | ||||||||
| Practice Location | |||||||||
| Address1: | 2400 SOUTH BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047743024 | ||||||||
| FaxNumber: | 7047743025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2015 | ||||||||
| LastUpdateDate: | 08/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | SHALA | ||||||||
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| AuthorizedOfficialTitleorPosition: | RCS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7043037517 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.