Provider Demographics
NPI:1376726935
Name:NOVANT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:MCKEE INTERNAL 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:7043-849-9094
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:704-384-7830
Practice Address - Street 1:3330 SISKEY PARKWAY
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105
Practice Address - Country:US
Practice Address - Phone:704-316-2127
Practice Address - Fax:704-316-2136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPB258Medicaid
NC019U2OtherBCBS-NC
NC5908614Medicaid
NC019U2OtherBCBS-NC