Basic Information
Provider Information | |||||||||
NPI: | 1487739058 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NOVANT MEDICAL GROUP, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NOVANT HEALTH WALKER PEDIATRICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 60447 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282600447 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7043841056 | ||||||||
FaxNumber: | 7043841046 | ||||||||
Practice Location | |||||||||
Address1: | 1918 RANDOLPH RD | ||||||||
Address2: | SUITE 700 | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282071100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7043841056 | ||||||||
FaxNumber: | 7043841046 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2006 | ||||||||
LastUpdateDate: | 03/06/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARDNER | ||||||||
AuthorizedOfficialFirstName: | GEOFFREY | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 7043841056 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | NPB213 | 05 | SC |   | MEDICAID | 018MF | 01 | NC | BCBS NC | OTHER | 5905369 | 05 | NC |   | MEDICAID |