Healthcare Provider Details

I. General information

NPI: 1265870026
Provider Name (Legal Business Name): NOVANT MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14215 BALLANTYNE CORPORATE PL SUITE 240
CHARLOTTE NC
28277-3670
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-5000
  • Fax: 704-316-5010
Mailing address:
  • Phone: 704-316-5000
  • Fax: 704-316-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: GEOFFREY GARDNER
Title or Position: VP OF FINANCE
Credential:
Phone: 704-384-7603