=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295089936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVANT MEDICAL GROUP, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2012
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1718 E 4TH ST STE 105
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28204-3193
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-384-5373
-----------------------------------------------------
Fax | 704-417-4400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 60447
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28260-0447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-384-7840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF NMG FINANCE
-----------------------------------------------------
Name | GEOFFREY K GARDNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-384-5373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------