Healthcare Provider Details

I. General information

NPI: 1932496312
Provider Name (Legal Business Name): NOVANT MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

10500 LIGON MILL RD SUITE 113
WAKE FOREST NC
27587-4576
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 919-496-1050
  • Fax: 919-496-0191
Mailing address:
  • Phone: 704-384-7840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GEOFFREY GARDNER
Title or Position: VP FINCANCE
Credential:
Phone: 704-384-9094