Basic Information
| Provider Information | |||||||||
| NPI: | 1215192695 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVANT MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | STATESVILLE ORTHOPEDICS & SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043847840 | ||||||||
| FaxNumber: | 7043847830 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 SIGNAL HILL DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286254483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048736065 | ||||||||
| FaxNumber: | 7048736058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2008 | ||||||||
| LastUpdateDate: | 08/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | PAI | ||||||||
| AuthorizedOfficialFirstName: | DINESH | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7043849113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1215192695 | 01 | NC | BCBS NC | OTHER |