Healthcare Provider Details

I. General information

NPI: 1518793025
Provider Name (Legal Business Name): NOVANT HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 RANDOLPH RD STE 700
CHARLOTTE NC
28207-1167
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 980-488-9630
  • Fax: 980-488-9635
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State

VIII. Authorized Official

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