Basic Information
| Provider Information | |||||||||
| NPI: | 1710228283 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVANT MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | NOVANT HEALTH LAKESIDE PHYSICAL THERAPY & SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043161265 | ||||||||
| FaxNumber: | 7043161266 | ||||||||
| Practice Location | |||||||||
| Address1: | 14330 OAKHILL PARK LANE | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | HUNTERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280783479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043161265 | ||||||||
| FaxNumber: | 7043161266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2013 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | GEOFFREY | ||||||||
| AuthorizedOfficialMiddleName: | KEITH | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7043847603 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.