Provider Demographics
NPI:1902846330
Name:NOVANT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:NOVANT HEALTH GYNECOLOGIC ONCOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHALA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-303-7517
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:
Practice Address - Street 1:1918 RANDOLPH RD STE 175
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1107
Practice Address - Country:US
Practice Address - Phone:704-384-8200
Practice Address - Fax:704-384-8208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC015KROtherBCBS NC
NC89015KRMedicaid
SCNPB048Medicaid
NC015KROtherBCBS NC