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	207Q00000X	Family Medicine Physician		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518967546
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	:	704-384-9920
Fax Number	:	704-384-9925

Provider Business Practice Location Address
First Line	:	4105 MATTHEWS MINT HILL RD
Second Line	:
City	:	MINT HILL
State	:	NC
Zip	:	28105-3633
Country	:	US
Telephone Number	:	704-384-9920
Fax Number	:	704-384-9925

Authorized Official
Title or Position	:	VP OF FINANCE
Name	:	GEOFFERY K GARDNER
Credential	:
Telephone Number	:	704-384-7606

Provider Enumeration Date	:	08/01/2005
Last Update Date	:	07/26/2013

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