Provider Demographics
NPI:1366683138
Name:NOVANT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP INC
Other - Org Name:CALABRETTA COSMETIC SURGERY CENTER
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:704-384-9094
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:704-444-5800
Mailing Address - Fax:704-444-5819
Practice Address - Street 1:1918 RANDOLPH RD
Practice Address - Street 2:SUITE 850
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1100
Practice Address - Country:US
Practice Address - Phone:704-444-5800
Practice Address - Fax:704-444-5819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-09
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911267Medicaid
NC5911267Medicaid