Basic Information
| Provider Information | |||||||||
| NPI: | 1376976043 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NOVANT MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | NOVANT HEALTH TRIAD SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043847840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 S HAWTHORNE RD | ||||||||
| Address2: | SUITE 480 | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367650155 | ||||||||
| FaxNumber: | 3367655494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2013 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | GEOFFREY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3367650155 | ||||||||
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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 | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1376976043 | 05 | NC | MEDICAID |