Basic Information
| Provider Information | |||||||||
| NPI: | 1386667368 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVANT MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | NOVANT HEALTH UNIVERSITY INTERNAL MEDICINE & PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043840570 | ||||||||
| FaxNumber: | 7043840571 | ||||||||
| Practice Location | |||||||||
| Address1: | 10320 MALLARD CREEK RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282625204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043840570 | ||||||||
| FaxNumber: | 7043840571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 11/29/2013 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | GEOFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7043849144 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 017WR | 01 | NC | BCBS | OTHER | CC5118 | 01 | NC | RAILROAD MEDICARE | OTHER | 5903443 | 05 | NC | MEDICAID |