Basic Information
| Provider Information | |||||||||
| NPI: | 1366772394 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVANT MEDICAL GROUP, INC | ||||||||
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| OtherOrganizationName: | MID CAROLINA CARDIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602362 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043849800 | ||||||||
| FaxNumber: | 7043472011 | ||||||||
| Practice Location | |||||||||
| Address1: | 8401 MEDICAL PLAZA DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282628797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048874531 | ||||||||
| FaxNumber: | 7043163821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2010 | ||||||||
| LastUpdateDate: | 10/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | GEOFFREY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3362772421 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NOVANT MEDICAL GROUP, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.