Healthcare Provider Details

I. General information

NPI: 1134765126
Provider Name (Legal Business Name): NOVANT MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 QUEENS RD
CHARLOTTE NC
28204-3217
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-9022
  • Fax: 704-316-9026
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHALA DAVIS
Title or Position: ENROLLMENT MANAGER
Credential:
Phone: 704-316-7845