Healthcare Provider Details

I. General information

NPI: 1255470274
Provider Name (Legal Business Name): NOVANT MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 LEE ANN DR NE SUITE 100
CONCORD NC
28025-2903
US

IV. Provider business mailing address

PO BOX 602362
CHARLOTTE NC
28260-2362
US

V. Phone/Fax

Practice location:
  • Phone: 704-788-1134
  • Fax: 704-788-1186
Mailing address:
  • Phone: 704-384-7840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: GEOFFREY GARDNER
Title or Position: VP OF OPERATIONS
Credential:
Phone: 704-384-9094