Provider Demographics
NPI:1356394308
Name:NOVANT HEALTH MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:NOVANT HEALTH MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:704-384-1775
Mailing Address - Fax:704-384-1776
Practice Address - Street 1:19485 OLD JETTON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6583
Practice Address - Country:US
Practice Address - Phone:704-384-1775
Practice Address - Fax:704-384-1776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207QS0010X
225100000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0215VOtherBCBS-NC
NC5903870Medicaid
NC2344688EMedicare PIN