Provider Demographics
NPI:1831199066
Name:NOVANT MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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: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:
Practice Address - Street 1:2555 COURT DR
Practice Address - Street 2:STE 300
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2134
Practice Address - Country:US
Practice Address - Phone:704-868-3256
Practice Address - Fax:704-332-3621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCDG5273OtherRAILROAD MEDICARE
SCNPA577Medicaid
NC5908575Medicaid
NC019H6OtherBCBS-NC
SCNPA577Medicaid