Provider Demographics
NPI:1982935805
Name:NOVANT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:NOVANT MEDICAL GROUP INC
Other - Org Name:NOVANT HEALTH BARIATRIC SOLUTIONS
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:704-316-7760
Mailing Address - Fax:704-316-7761
Practice Address - Street 1:325 HAWTHORNE LN STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2536
Practice Address - Country:US
Practice Address - Phone:704-316-7760
Practice Address - Fax:704-316-7761
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOVANT MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-15
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2319872Medicare UPIN