Healthcare Provider Details

I. General information

NPI: 1437641164
Provider Name (Legal Business Name): NOVANT MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 JAKE ALEXANDER BLVD W STE 303
SALISBURY NC
28147-1177
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-718-1970
  • Fax: 336-774-8601
Mailing address:
  • Phone: 336-718-1970
  • Fax: 704-774-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number
License Number State

VIII. Authorized Official

Name: GEOFFREY K GARDNER
Title or Position: VP OF FINANCE
Credential:
Phone: 704-384-7840