Provider Demographics
| NPI: | 1346398435 |
|---|---|
| Name: | NOVANT MEDICAL GROUP, INC |
| Entity type: | Organization |
| Organization Name: | NOVANT MEDICAL GROUP, INC |
| Other - Org Name: | |
| Other - Org Type: | |
| 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: | 704-384-7830 |
| Practice Address - Street 1: | 108 PROVIDENCE RD |
| Practice Address - Street 2: | |
| Practice Address - City: | CHARLOTTE |
| Practice Address - State: | NC |
| Practice Address - Zip Code: | 28207-1218 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 704-384-9679 |
| Practice Address - Fax: | 704-316-0508 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2007-01-08 |
| Last Update Date: | 2011-10-06 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207VM0101X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | Group - Multi-Specialty |
| No | 207VX0201X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | Group - Multi-Specialty |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2080N0001X | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | Group - Multi-Specialty |
| No | 2080P0202X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | Group - Multi-Specialty |
| No | 2080P0207X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | Group - Multi-Specialty |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Multi-Specialty |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| NC | 2344688G | Medicare PIN | |
| NC | 2319872E | Medicare PIN | |
| NC | 2319872H | Medicare PIN | |
| NC | 2322229C | Medicare PIN | |
| NC | 2343183B | Medicare PIN | |
| NC | 2344688 | Medicare PIN | |
| NC | 2344688D | Medicare PIN | |
| NC | 2319872D | Medicare PIN | |
| NC | 2319872 | Medicare PIN | |
| NC | 2319872T | Medicare PIN | |
| NC | 2322229A | Medicare PIN | |
| NC | 2325721 | Medicare PIN | |
| NC | 2343183G | Medicare PIN | |
| NC | 2343183T | Medicare PIN | |
| NC | 2322229E | Medicare PIN | |
| NC | 2319872M | Medicare PIN | |
| NC | 2343183E | Medicare PIN | |
| NC | 2319872S | Medicare PIN | |
| NC | 2319872K | Medicare PIN | |
| NC | 2344668B | Medicare PIN |
