Healthcare Provider Details

I. General information

NPI: 1801565684
Provider Name (Legal Business Name): NOVANT HEALTH MEDICAL GROUP COASTAL REGION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 EMERSON BAY RD STE 104
CAROLINA SHORES NC
28467-2498
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-667-4283
  • Fax: 910-338-0965
Mailing address:
  • Phone: 910-667-4283
  • Fax: 910-338-0965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHALA DAVIS
Title or Position: ENROLLMENT MANAGER
Credential:
Phone: 704-303-7517