Provider Demographics
NPI: | 1356853162 |
---|---|
Name: | NOVANT MEDICAL GROUP, INC. |
Entity Type: | Organization |
Organization Name: | NOVANT MEDICAL GROUP, INC. |
Other - Org Name: | NOVANT HEALTH BERMUDA RUN FAMILY MEDICINE |
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: | 704-384-7840 |
Mailing Address - Street 1: | PO BOX 60447 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLOTTE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28260-0447 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 704-384-7840 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 5380 US HIGHWAY 158 STE 110 |
Practice Address - Street 2: | |
Practice Address - City: | ADVANCE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 27006-6974 |
Practice Address - Country: | US |
Practice Address - Phone: | 336-893-3210 |
Practice Address - Fax: | 336-893-3229 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-11-02 |
Last Update Date: | 2017-12-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty |