Provider Demographics
NPI:1235458985
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:919-570-5705
Mailing Address - Fax:919-570-5710
Practice Address - Street 1:10500 LIGON MILL RD
Practice Address - Street 2:SUITE 113
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4576
Practice Address - Country:US
Practice Address - Phone:919-570-5705
Practice Address - Fax:919-570-5710
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOVANT MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-20
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5914970Medicaid
NC5914970Medicaid