Provider Demographics
NPI:1821248196
Name:NOVANT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:NORTHLAKE NEUROLOGY - HUNTERSVILLE
Other - Org Type:Other Name
Authorized Official - Title/Position:VP OF FINANCE
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: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 1:16525 HOLLY CREST LN
Practice Address - Street 2:SUITE 120
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-4909
Practice Address - Country:US
Practice Address - Phone:704-316-5388
Practice Address - Fax:704-316-1848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty