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	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1124317755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVANT MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:	704-384-7840
Fax Number	:	704-384-7830

Provider Business Practice Location Address
First Line	:	3614 PROVIDENCE RD
Second Line	:
City	:	WAXHAW
State	:	NC
Zip	:	28173-6309
Country	:	US
Telephone Number	:	704-384-1246
Fax Number	:	704-384-6072

Authorized Official
Title or Position	:	VP OF FINANCE
Name	:	GEOFFREY K GARDNER
Credential	:
Telephone Number	:	704-384-9094

Provider Enumeration Date	:	04/05/2011
Last Update Date	:	04/05/2011

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