MEDICARE: NOVANT HEALTH MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CC5118	OTHER	NC	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0276T	OTHER	NC	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568400729
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVANT HEALTH MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:	704-384-8640
Fax Number	:	704-384-8650

Provider Business Practice Location Address
First Line	:	3614 PROVIDENCE RD S
Second Line	:	SUITE 100
City	:	WAXHAW
State	:	NC
Zip	:	28173-6309
Country	:	US
Telephone Number	:	704-384-8640
Fax Number	:	704-384-8650

Authorized Official
Title or Position	:	RCS MANAGER
Name	:	LEEA JEANINE WALTON
Credential	:
Telephone Number	:	704-316-6081

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/09/2024

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Directions to “NOVANT HEALTH MEDICAL GROUP, LLC ” Practice Location

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