Provider Demographics
NPI:1992019525
Name:NOVANT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:NEUSE VALLEY INTERNAL 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 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:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:701 EXPOSITION PL
Practice Address - Street 2:SUITE 218
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3300
Practice Address - Country:US
Practice Address - Phone:919-791-2900
Practice Address - Fax:919-845-2568
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOVANT MEDICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty