Provider Demographics
NPI:1164705653
Name:NOVANT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP INC
Other - Org Name:PEDIATRIC GASTROENTEROLOGY ASSOCIATES (SATELLITE)
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE NMG
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:P O BOX 60447
Mailing Address - Street 2:NOVANT MEDICAL GROUP, INC.
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:704-316-5060
Mailing Address - Fax:704-316-5069
Practice Address - Street 1:16139 LANCASTER HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2033
Practice Address - Country:US
Practice Address - Phone:704-316-5060
Practice Address - Fax:704-316-5069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919443Medicaid
NC2322229XMedicare PIN