MEDICARE: NOVANT MEDICAL GROUP, INC

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	2084N0400X	Neurology Physician

General Provider Information

NPI Number	:	1528322617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVANT MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:	336-765-5553
Fax Number	:	336-765-5359

Provider Business Practice Location Address
First Line	:	1471 JAG BRANCH BLVD STE 105
Second Line	:
City	:	KERNERSVILLE
State	:	NC
Zip	:	27284-6956
Country	:	US
Telephone Number	:	336-765-5553
Fax Number	:	336-765-5359

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

Provider Enumeration Date	:	07/03/2012
Last Update Date	:	06/09/2022

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