Healthcare Provider Details

I. General information

NPI: 1316245475
Provider Name (Legal Business Name): NOVANT MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2011
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15825 JOHN J DELANEY DR SUITE 220
CHARLOTTE NC
28277-3147
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-7740
  • Fax: 704-316-7745
Mailing address:
  • Phone: 704-316-7740
  • Fax: 704-316-7745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GEOFFREY GARDNER
Title or Position: VP FINANCE
Credential:
Phone: 704-384-9094