Basic Information
| Provider Information | |||||||||
| NPI: | 1376726935 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVANT MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCKEE INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043847840 | ||||||||
| FaxNumber: | 7043847830 | ||||||||
| Practice Location | |||||||||
| Address1: | 3330 SISKEY PARKWAY | ||||||||
| Address2: | |||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043162127 | ||||||||
| FaxNumber: | 7043162136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2007 | ||||||||
| LastUpdateDate: | 08/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | GEOFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 70438499094 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | NPB258 | 05 | SC | MEDICAID | 019U2 | 01 | NC | BCBS-NC | OTHER | 5908614 | 05 | NC | MEDICAID |