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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1548405731
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	:	704-316-1670
Fax Number	:	704-316-1675

Provider Business Practice Location Address
First Line	:	13557 STEELECROFT PKWY STE 2100
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28278-7559
Country	:	US
Telephone Number	:	704-316-1670
Fax Number	:	704-316-1675

Authorized Official
Title or Position	:	VP OPERATIONS
Name	:	MR. GEOFFREY GARDNER
Credential	:
Telephone Number	:	704-384-9240

Provider Enumeration Date	:	12/03/2008
Last Update Date	:	06/28/2013

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