Provider Demographics
NPI:1144410937
Name:NOVANT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:OCEAN ISLE FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-384-9094
Mailing Address - Street 1:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:910-575-5245
Practice Address - Street 1:120 CAUSEWAY DR
Practice Address - Street 2:SUITE 4
Practice Address - City:OCEAN ISLE BEACH
Practice Address - State:NC
Practice Address - Zip Code:28469-7538
Practice Address - Country:US
Practice Address - Phone:910-575-5242
Practice Address - Fax:910-575-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908211Medicaid
NCDG7127OtherRAILROAD MEDICARE
NC019T3OtherBCBS OF NC
NC019T3OtherBCBS OF NC