Healthcare Provider Details

I. General information

NPI: 1649428848
Provider Name (Legal Business Name): NOVANT MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 JAKE ALEXANDER BLVD W SUITE 301
SALISBURY NC
28147-1178
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-637-1888
  • Fax: 704-637-1880
Mailing address:
  • Phone: 704-637-1888
  • Fax: 704-637-1880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

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