Healthcare Provider Details

I. General information

NPI: 1114960069
Provider Name (Legal Business Name): NOVANT HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 MATTHEWS TOWNSHIP PKWY STE 355
MATTHEWS NC
28105-4300
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-6020
  • Fax: 704-384-6025
Mailing address:
  • Phone: 704-384-6020
  • Fax: 704-384-6025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier71098
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS NC
# 2
IdentifierCC5118
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerRAILROAD MEDICARE
# 3
Identifier5906187
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 4
IdentifierNPB227
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

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