Provider Demographics
NPI:1982841243
Name:NOVANT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP INC
Other - Org Name:NOVANT HEALTH PEACHVIEW 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:704-384-9094
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:864-488-1400
Mailing Address - Fax:864-488-1057
Practice Address - Street 1:722 HYATT ST
Practice Address - Street 2:SUITE B
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-2643
Practice Address - Country:US
Practice Address - Phone:864-488-1400
Practice Address - Fax:864-488-1057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5091Medicaid
SCGP5091Medicaid