1417362781 NPI number — NOVANT MEDICAL GROUP, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417362781 NPI number — NOVANT MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOVANT MEDICAL GROUP, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NOVANT HEALTH ARCHDALE FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417362781
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-564-4161
Provider Business Mailing Address Fax Number:
336-431-0084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1718 EAST 4TH STREET
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28260-0447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-564-4161
Provider Business Practice Location Address Fax Number:
336-431-0084
Provider Enumeration Date:
06/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
GEOFFREY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
VP OF FINANCE
Authorized Official Telephone Number:
704-384-7606

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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