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	208000000X	Pediatrics Physician		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	012E7	OTHER	NC	BCBS NC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891735312
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	:	704-384-1570
Fax Number	:	704-384-1534

Provider Business Practice Location Address
First Line	:	8401 MEDICAL PLAZA DR
Second Line	:	SUITE 220
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-8700
Country	:	US
Telephone Number	:	704-384-1570
Fax Number	:	704-384-1534

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

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	06/20/2024

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