Healthcare Provider Details

I. General information

NPI: 1184679359
Provider Name (Legal Business Name): NOVANT HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14215 BALLANTYNE CORPORATE PL SUITE 130
CHARLOTTE NC
28277-3671
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-1950
  • Fax: 704-384-1955
Mailing address:
  • Phone: 704-384-7283
  • Fax: 704-316-0508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: LEEA JEANINE WALTON
Title or Position: RCS MANAGER
Credential:
Phone: 704-316-6081