MEDICARE: NOVANT MEDICAL GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	015YP	OTHER	NC	BCBS NC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114967619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVANT MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 602362
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-2362
Country	:	US
Telephone Number	:	704-384-1605
Fax Number	:	704-384-1610

Provider Business Practice Location Address
First Line	:	330 BILLINGSLEY RD
Second Line	:	SUITE 101
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-5020
Country	:	US
Telephone Number	:	704-384-1605
Fax Number	:	704-384-1610

Authorized Official
Title or Position	:	VP FINANCE
Name	:	GEOFFERY GARDNER
Credential	:
Telephone Number	:	704-384-7283

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	07/31/2013

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