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	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1972464899
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	:	704-316-7760
Fax Number	:	704-316-7761

Provider Business Practice Location Address
First Line	:	773 STOCKBRIDGE DR
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-7200
Country	:	US
Telephone Number	:	704-316-7760
Fax Number	:	704-316-7761

Authorized Official
Title or Position	:	ENROLLMENT MANAGER
Name	:	LEEA JEANINE WALTON
Credential	:
Telephone Number	:	336-515-7085

Provider Enumeration Date	:	11/20/2025
Last Update Date	:	12/10/2025

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