Provider Demographics
NPI:1053634824
Name:NOVA IC, INC.
Entity type:Organization
Organization Name:NOVA IC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIDGEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:919-734-8803
Mailing Address - Street 1:PO BOX 11077
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27532-1077
Mailing Address - Country:US
Mailing Address - Phone:919-734-8803
Mailing Address - Fax:919-735-6825
Practice Address - Street 1:2307 NORWOOD AVE STE A
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-1601
Practice Address - Country:US
Practice Address - Phone:919-735-8887
Practice Address - Fax:919-735-8871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406164Medicaid
NC340608VMedicaid
NC3406058Medicaid
NC340610MMedicaid
NC8302565Medicaid
NC6006439Medicaid
NC3406289Medicaid
NC3406312Medicaid
NC340609RMedicaid
NC3406174Medicaid
NC8302772Medicaid