MEDICARE: NOVANT HEALTH MEDICAL GROUP COASTAL REGION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1457946519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVANT HEALTH MEDICAL GROUP COASTAL REGION, LLC

Provider Business Mailing Address
First Line	:	PO BOX 936857
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31193-6857
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7910 US HWY 117 S
Second Line	:
City	:	ROCKY POINT
State	:	NC
Zip	:	28457-9431
Country	:	US
Telephone Number	:	910-300-4500
Fax Number	:

Authorized Official
Title or Position	:	RCS MANAGER
Name	:	SHALA DAVIS
Credential	:
Telephone Number	:	704-303-7517

Provider Enumeration Date	:	03/01/2021
Last Update Date	:	07/19/2021

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