Provider Demographics
NPI:1164781845
Name:NOVANT MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP, INC
Other - Org Name:NOVANT HEALTH PINE LAKE FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEEA
Authorized Official - Middle Name:JEANINE
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-316-6081
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-9090
Mailing Address - Fax:704-316-9095
Practice Address - Street 1:7800 STEVENS MILL RD
Practice Address - Street 2:SUITE 0
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-6111
Practice Address - Country:US
Practice Address - Phone:704-316-9090
Practice Address - Fax:704-316-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty