Basic Information
| Provider Information | |||||||||
| NPI: | 1831199066 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVANT MEDICAL GROUP, INC. | ||||||||
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| OtherOrganizationName: | MID CAROLINA CARDIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602362 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043847840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2555 COURT DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048683256 | ||||||||
| FaxNumber: | 7043323621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 07/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | GEOFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7043849094 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | DG5273 | 01 | NC | RAILROAD MEDICARE | OTHER | NPA577 | 05 | SC | MEDICAID | 5908575 | 05 | NC | MEDICAID | 019H6 | 01 | NC | BCBS-NC | OTHER |