Healthcare Provider Details

I. General information

NPI: 1144410937
Provider Name (Legal Business Name): NOVANT MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 CAUSEWAY DR SUITE 4
OCEAN ISLE BEACH NC
28469-7538
US

IV. Provider business mailing address

PO BOX 602362
CHARLOTTE NC
28260-2362
US

V. Phone/Fax

Practice location:
  • Phone: 910-575-5242
  • Fax: 910-575-5245
Mailing address:
  • Phone: 704-384-7840
  • Fax: 910-575-5245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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