Healthcare Provider Details

I. General information

NPI: 1245335421
Provider Name (Legal Business Name): NOVANT HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6237 CAROLINA COMMONS DR SUITE 101
INDIAN LAND SC
29707-6014
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-9393
  • Fax: 803-548-9590
Mailing address:
  • Phone: 704-384-7840
  • Fax: 704-384-7830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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