Provider Demographics
NPI:1326176561
Name:NOVANT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:NOVANT HEALTH SOUTHEAST OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:K
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-321-1077
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:704-321-1077
Mailing Address - Fax:704-321-1086
Practice Address - Street 1:1450 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:STE 300
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5332
Practice Address - Country:US
Practice Address - Phone:704-321-1077
Practice Address - Fax:704-321-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC011V2OtherBCBS NC
NC5907956Medicaid
NC011V2OtherBCBS NC