Provider Demographics
NPI:1962872069
Name:NOVA FAMILY PRACTICE
Entity type:Organization
Organization Name:NOVA FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-672-0095
Mailing Address - Street 1:1813 S GLENBURNIE RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5210
Mailing Address - Country:US
Mailing Address - Phone:252-672-0095
Mailing Address - Fax:252-672-9897
Practice Address - Street 1:4252 ARENDELL ST STE A
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-0015
Practice Address - Country:US
Practice Address - Phone:252-222-0204
Practice Address - Fax:252-222-0433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-01
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC213209207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty